Provider Demographics
NPI:1700556420
Name:BLOOM, EDWARD PATRICK (COTA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:PATRICK
Last Name:BLOOM
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:43624 APPOMATTOX CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1707
Mailing Address - Country:US
Mailing Address - Phone:734-634-1273
Mailing Address - Fax:
Practice Address - Street 1:28910 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2337
Practice Address - Country:US
Practice Address - Phone:734-425-4814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
5202008088224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant