Provider Demographics
NPI:1184396426
Name:BLOOM, ANDREA HOPE
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:HOPE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12292 W DOMINO DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-4081
Mailing Address - Country:US
Mailing Address - Phone:206-235-1115
Mailing Address - Fax:
Practice Address - Street 1:7219 N LITCHFIELD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85309-1529
Practice Address - Country:US
Practice Address - Phone:623-856-7579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0655101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical