Healthcare Provider Details

I. General information

NPI: 1497810683
Provider Name (Legal Business Name): JUDITH F. BLOOM LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 08/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RESEARCH PKWY SUITE C
OLD SAYBROOK CT
06475-4214
US

IV. Provider business mailing address

10 GROTTO AVE
PROVIDENCE RI
02906-5517
US

V. Phone/Fax

Practice location:
  • Phone: 800-370-3651
  • Fax: 860-510-0020
Mailing address:
  • Phone: 401-450-5916
  • Fax: 860-510-0020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01344
License Number StateRI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier413409
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CHIP
# 2
Identifier1021740
Identifier TypeOTHER
Identifier State
Identifier IssuerNHP GROUP NUMBER
# 3
Identifier31344-7
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CROSS BLUE SHIELD
# 4
IdentifierJB01344
Identifier TypeMEDICAID
Identifier StateRI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: