MEDICARE: ILYSE BLOOM LMFT

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	1739	CO

General Provider Information

NPI Number	:	1821662396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILYSE BLOOM LMFT

Provider Business Mailing Address
First Line	:	3100 ARAPAHOE AVE STE 101
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-1050
Country	:	US
Telephone Number	:	130-393-1849
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 ARAPAHOE AVE STE 101
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80303-1050
Country	:	US
Telephone Number	:	130-393-1849
Fax Number	:

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

Provider Enumeration Date	:	05/18/2021
Last Update Date	:	05/18/2021

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Directions to “ ILYSE BLOOM LMFT” Practice Location

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