Provider Demographics
NPI:1922187376
Name:BLOOM, AUDREY (PHD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9555 FENBROOK CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD
Practice Address - Street 2:BUILDING 300, SUITE 315
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2002
Practice Address - Country:US
Practice Address - Phone:678-935-9567
Practice Address - Fax:678-935-9568
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001866103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist