Provider Demographics
NPI:1760834907
Name:BLOOM, MELISSA (DPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12072 W DUMBARTON DR
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:CO
Mailing Address - Zip Code:80465-2005
Mailing Address - Country:US
Mailing Address - Phone:219-680-9441
Mailing Address - Fax:
Practice Address - Street 1:3333 S WADSWORTH BLVD
Practice Address - Street 2:321
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80227-5122
Practice Address - Country:US
Practice Address - Phone:303-985-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0011424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist