Provider Demographics
NPI:1518251925
Name:BLOOM, AMANDA (BCBA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3671 TURTLE RUN BLVD
Mailing Address - Street 2:APT. 1331
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-4213
Mailing Address - Country:US
Mailing Address - Phone:954-856-6926
Mailing Address - Fax:
Practice Address - Street 1:3671 TURTLE RUN BLVD
Practice Address - Street 2:APT. 1331
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-4213
Practice Address - Country:US
Practice Address - Phone:954-856-6926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-13-14404103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst