Provider Demographics
NPI:1710330568
Name:BLOOMER, MARY KATE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY KATE
Middle Name:
Last Name:BLOOMER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 BLOOMER PATH
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:MA
Mailing Address - Zip Code:02631-1240
Mailing Address - Country:US
Mailing Address - Phone:508-221-5745
Mailing Address - Fax:
Practice Address - Street 1:873 HARWICH RD
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-5232
Practice Address - Country:US
Practice Address - Phone:508-896-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2542174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2542OtherDIVISION OF PROFESSIONAL PROFESSIONAL LICENSURE