Provider Demographics
NPI:1740466929
Name:BLOOM-BRAZER, RANDI (LCSW)
Entity type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:
Last Name:BLOOM-BRAZER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12924 SW 119TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4556
Mailing Address - Country:US
Mailing Address - Phone:305-790-9798
Mailing Address - Fax:
Practice Address - Street 1:165 SOUTHPARK BLVD
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4101
Practice Address - Country:US
Practice Address - Phone:904-824-7597
Practice Address - Fax:904-824-7598
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 50421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical