Healthcare Provider Details

I. General information

NPI: 1427759406
Provider Name (Legal Business Name): KRISTIN BLOOMER ARCHDEACON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E SANTA CLARA ST STE 105
SAN JOSE CA
95112-1936
US

IV. Provider business mailing address

55 S 14TH ST # 2
SAN JOSE CA
95112-2016
US

V. Phone/Fax

Practice location:
  • Phone: 408-961-4645
  • Fax:
Mailing address:
  • Phone: 408-829-2673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW80860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: