Provider Demographics
NPI:1700144060
Name:BLOOM, GABRIELLE ELENA (BCBA)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ELENA
Last Name:BLOOM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2102 LAC DU MONT APT C2
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-9518
Mailing Address - Country:US
Mailing Address - Phone:619-244-1913
Mailing Address - Fax:
Practice Address - Street 1:2814 WOODCLIFF CIR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-3155
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-10114103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst