Provider Demographics
NPI:1891304986
Name:BLOOM PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:BLOOM PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:917-727-0825
Mailing Address - Street 1:2330 NW FLANDERS ST STE 107
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3400
Mailing Address - Country:US
Mailing Address - Phone:917-727-0825
Mailing Address - Fax:
Practice Address - Street 1:2330 NW FLANDERS ST STE 107
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3400
Practice Address - Country:US
Practice Address - Phone:917-727-0825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health