Provider Demographics
NPI:1255027363
Name:BLOOM, THEA (CGC)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3647 N KEELER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-3014
Mailing Address - Country:US
Mailing Address - Phone:773-208-5239
Mailing Address - Fax:
Practice Address - Street 1:1950 W POLK ST
Practice Address - Street 2:FL 7 CUB 64
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3726
Practice Address - Country:US
Practice Address - Phone:312-864-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL247.000180170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS