Healthcare Provider Details

I. General information

NPI: 1184595951
Provider Name (Legal Business Name): LAURA BLOM ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 SISK RD
MODESTO CA
95356-8870
US

IV. Provider business mailing address

3200 TULLY RD
MODESTO CA
95350-0811
US

V. Phone/Fax

Practice location:
  • Phone: 209-545-7500
  • Fax:
Mailing address:
  • Phone: 209-576-2283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW107006
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: