Provider Demographics
NPI:1770615080
Name:BLOOM, KIMBERLY N (MS CCC- SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:N
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MS CCC- SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8075 NW 15TH MNR
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-5453
Mailing Address - Country:US
Mailing Address - Phone:954-424-1630
Mailing Address - Fax:954-559-5987
Practice Address - Street 1:12545 ORANGE DR STE 502
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4306
Practice Address - Country:US
Practice Address - Phone:954-236-9504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6787235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC8885061Medicaid