Provider Demographics
NPI:1528179371
Name:BLOOM, DONNA KAY (MFT)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:KAY
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MISS
Other - First Name:DONNA
Other - Middle Name:KAY
Other - Last Name:LONDEREE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91503-0903
Mailing Address - Country:US
Mailing Address - Phone:818-841-1300
Mailing Address - Fax:323-225-6120
Practice Address - Street 1:353 E ANGELENO AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1310
Practice Address - Country:US
Practice Address - Phone:818-841-1300
Practice Address - Fax:323-225-6120
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM22760106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist