Provider Demographics
NPI:1013120526
Name:BLOOM, STACY (R LCSW)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:R LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600-11-4B PINE HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:11732
Mailing Address - Country:US
Mailing Address - Phone:516-922-6219
Mailing Address - Fax:
Practice Address - Street 1:600-11-4B PINE HOLLOW ROAD
Practice Address - Street 2:
Practice Address - City:EAST NORWICH
Practice Address - State:NY
Practice Address - Zip Code:11732
Practice Address - Country:US
Practice Address - Phone:516-922-6219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04239911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical