Provider Demographics
NPI:1972659621
Name:BLOOM, AMY E (LISW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 ASPEN DRIVE
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5579
Mailing Address - Country:US
Mailing Address - Phone:505-474-7777
Mailing Address - Fax:505-424-1975
Practice Address - Street 1:1925 ASPEN DRIVE
Practice Address - Street 2:SUITE 100B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5579
Practice Address - Country:US
Practice Address - Phone:505-474-7777
Practice Address - Fax:505-424-1975
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-054431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical