MEDICARE: MS. LORI G BLOOM MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist		CA

General Provider Information

NPI Number	:	1356886220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORI G BLOOM MFT

Provider Business Mailing Address
First Line	:	44551 LITTLE RIVER AIRPORT RD
Second Line	:
City	:	LITTLE RIVER
State	:	CA
Zip	:	95456-9679
Country	:	US
Telephone Number	:	707-937-3532
Fax Number	:

Provider Business Practice Location Address
First Line	:	44551 LITTLE RIVER AIRPORT RD
Second Line	:
City	:	LITTLE RIVER
State	:	CA
Zip	:	95456-9679
Country	:	US
Telephone Number	:	707-937-3532
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2016
Last Update Date	:	12/30/2016

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