Provider Demographics
NPI:1750615068
Name:BLOOM, SANDRA L
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LYNN
Other - Last Name:TREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:13 DRUIM MOIR LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-4134
Mailing Address - Country:US
Mailing Address - Phone:215-248-5357
Mailing Address - Fax:215-248-5367
Practice Address - Street 1:13 DRUIM MOIR LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-4134
Practice Address - Country:US
Practice Address - Phone:215-248-5357
Practice Address - Fax:215-248-5367
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD019329E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry