Provider Demographics
NPI:1184171696
Name:BLOOM, KELSEY RAE GEORGE (PT, DPT)
Entity type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:RAE GEORGE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:RAE
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:7349 S 69TH ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9208
Mailing Address - Country:US
Mailing Address - Phone:608-219-3676
Mailing Address - Fax:
Practice Address - Street 1:1585 N MILWAUKEE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-1359
Practice Address - Country:US
Practice Address - Phone:847-918-7947
Practice Address - Fax:847-918-9622
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13535-24225100000X
IL070.022615225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist