Provider Demographics
NPI:1790726172
Name:BLOOMGARDEN, REBECCA (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BLOOMGARDEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 GREENBRIAR PL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7637
Mailing Address - Country:US
Mailing Address - Phone:405-692-3015
Mailing Address - Fax:
Practice Address - Street 1:10400 GREENBRIAR PL
Practice Address - Street 2:SUITE 104
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7637
Practice Address - Country:US
Practice Address - Phone:405-692-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1293-OK LCSW1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical