Provider Demographics
NPI:1750588208
Name:BLOOM, CHARLES WARREN (BS,MS,CTRS)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WARREN
Last Name:BLOOM
Suffix:
Gender:M
Credentials:BS,MS,CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 ELWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60481-1026
Mailing Address - Country:US
Mailing Address - Phone:815-476-2348
Mailing Address - Fax:
Practice Address - Street 1:15900 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-4006
Practice Address - Country:US
Practice Address - Phone:708-633-3066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist