Healthcare Provider Details

I. General information

NPI: 1396989141
Provider Name (Legal Business Name): SUSAN JONE BLOOM PSY. D., APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6513 SANDPIPER DR
COCONUT CREEK FL
33073-2414
US

IV. Provider business mailing address

777 N JEFFERSON ST STE 408
MILWAUKEE WI
53202-3875
US

V. Phone/Fax

Practice location:
  • Phone: 414-455-0626
  • Fax: 414-455-0626
Mailing address:
  • Phone: 847-372-9612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5697
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11017246
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5697
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: