Provider Demographics
NPI:1952794950
Name:BLOOM, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 PINE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3029
Mailing Address - Country:US
Mailing Address - Phone:616-901-2777
Mailing Address - Fax:616-336-4333
Practice Address - Street 1:1558 PINE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3029
Practice Address - Country:US
Practice Address - Phone:616-901-2777
Practice Address - Fax:616-336-4333
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-15
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401001493101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101YO2500XMedicaid