Provider Demographics
NPI:1013112242
Name:BLOOMQUIST, HOLLY RENAE (DPT)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:RENAE
Last Name:BLOOMQUIST
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3828 CAMINITO LITORAL # 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-1902
Mailing Address - Country:US
Mailing Address - Phone:619-708-8262
Mailing Address - Fax:
Practice Address - Street 1:4510 VIEWRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1637
Practice Address - Country:US
Practice Address - Phone:858-502-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA286002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics