Provider Demographics
NPI:1790255164
Name:BLOOM, KYRA L (LMT)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:L
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2780
Mailing Address - Country:US
Mailing Address - Phone:419-352-8946
Mailing Address - Fax:419-352-8947
Practice Address - Street 1:536 PEARL ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2780
Practice Address - Country:US
Practice Address - Phone:419-352-8946
Practice Address - Fax:419-352-8947
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023053225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist