Provider Demographics
NPI:1609460468
Name:BLOOM, MICHELLE (MA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MERRIMACK ST STE 201
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-1707
Mailing Address - Country:US
Mailing Address - Phone:978-455-0756
Mailing Address - Fax:978-455-0770
Practice Address - Street 1:100 MERRIMACK ST STE 201
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1707
Practice Address - Country:US
Practice Address - Phone:978-455-0756
Practice Address - Fax:978-455-0770
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MALMHC10000465101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health