Provider Demographics
NPI:1518638204
Name:BLOOMUS, LORI ANN
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:ANN
Last Name:BLOOMUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2121
Mailing Address - Country:US
Mailing Address - Phone:203-833-0033
Mailing Address - Fax:
Practice Address - Street 1:308 JAMES ST
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-2121
Practice Address - Country:US
Practice Address - Phone:203-833-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CT2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No174400000XOther Service ProvidersSpecialist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer