Provider Demographics
NPI:1780150805
Name:BLOOM, RENAY ANTOINETTE (CHEMICAL DEPENDENCY)
Entity type:Individual
Prefix:MRS
First Name:RENAY
Middle Name:ANTOINETTE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:CHEMICAL DEPENDENCY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N. 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901
Mailing Address - Country:US
Mailing Address - Phone:509-469-9366
Mailing Address - Fax:509-469-9926
Practice Address - Street 1:315 N. 2ND STREET
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901
Practice Address - Country:US
Practice Address - Phone:509-469-9366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)