Provider Demographics
NPI:1750398640
Name:BLOOM, PHYLLIS (LSW, LAC)
Entity type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LSW, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 SIXTH AVENUE
Mailing Address - Street 2:SUITE #1108
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:212-967-1393
Mailing Address - Fax:212-967-5996
Practice Address - Street 1:875 SIXTH AVENUE
Practice Address - Street 2:SUITE #1108
Practice Address - City:NY
Practice Address - State:NY
Practice Address - Zip Code:10001
Practice Address - Country:US
Practice Address - Phone:212-967-1393
Practice Address - Fax:212-967-5996
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0162401104100000X
NY203-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN23701Medicare ID - Type Unspecified