Provider Demographics
NPI:1972612513
Name:BLOOME, ELLEN (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BLOOME
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7539 DIAMOND POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-3344
Mailing Address - Country:US
Mailing Address - Phone:561-558-3316
Mailing Address - Fax:
Practice Address - Street 1:7539 DIAMOND POINTE CIR
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33446-3344
Practice Address - Country:US
Practice Address - Phone:561-558-3316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36569225100000X
FL66592251G0304X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7544AMedicare ID - Type UnspecifiedPROVIDER NUMBER