Provider Demographics
NPI:1942562400
Name:BLOOM, IVY (MSED)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 JEFFERY LN
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5936
Mailing Address - Country:US
Mailing Address - Phone:516-678-3728
Mailing Address - Fax:
Practice Address - Street 1:122 JEFFERY LN
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5936
Practice Address - Country:US
Practice Address - Phone:516-678-3728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist