Provider Demographics
NPI:1972084127
Name:BLOOM, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:EWALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:695 DRAPER RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:41097-4867
Mailing Address - Country:US
Mailing Address - Phone:513-515-4428
Mailing Address - Fax:
Practice Address - Street 1:100 SPRING HARBOR DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4619
Practice Address - Country:US
Practice Address - Phone:706-641-0424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-26
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1972084127Medicaid