Provider Demographics
NPI:1538133400
Name:BLOOM, ELLEN MARCIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:MARCIE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26205 116TH AVE SE
Mailing Address - Street 2:A-202
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-8497
Mailing Address - Country:US
Mailing Address - Phone:253-850-1126
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER, 9040 REID ST.
Practice Address - Street 2:ATTN:MCHJ-QCR
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-6546
Practice Address - Fax:253-968-5602
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051758001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical