MEDICARE: KATHLEEN BLOOM

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	101YP2500X	Professional Counselor	6401001493	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952794950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN BLOOM

Provider Business Mailing Address
First Line	:	1558 PINE AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3029
Country	:	US
Telephone Number	:	616-901-2777
Fax Number	:	616-336-4333

Provider Business Practice Location Address
First Line	:	1558 PINE AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3029
Country	:	US
Telephone Number	:	616-901-2777
Fax Number	:	616-336-4333

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

Provider Enumeration Date	:	03/15/2015
Last Update Date	:	03/15/2015

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Directions to “ KATHLEEN BLOOM ” Practice Location

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