Provider Demographics
NPI:1609484898
Name:BLOOM, KENDRA SUNDIN (BCBA, LBA)
Entity Type:Individual
Prefix:MS
First Name:KENDRA
Middle Name:SUNDIN
Last Name:BLOOM
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 W. WASHINGTON ST. SUITE 5
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-0000
Mailing Address - Country:US
Mailing Address - Phone:906-273-1121
Mailing Address - Fax:906-225-6706
Practice Address - Street 1:1229 W. WASHINGTON ST. SUITE 5
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-0000
Practice Address - Country:US
Practice Address - Phone:906-273-1121
Practice Address - Fax:906-225-6706
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI20045130244106E00000X
MI20258150925103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst