Healthcare Provider Details

I. General information

NPI: 1275713356
Provider Name (Legal Business Name): RUTH A. GOLDBLOOM, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12590 NATIONAL PIKE SUITE 2
GRANTSVILLE MD
21536-3310
US

IV. Provider business mailing address

12590 NATIONAL PIKE P O BOX 268
GRANTSVILLE MD
21536-3310
US

V. Phone/Fax

Practice location:
  • Phone: 301-895-3388
  • Fax: 301-895-3399
Mailing address:
  • Phone: 301-895-3388
  • Fax: 301-895-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. RUTH ALICE GOLDBLOOM
Title or Position: OWNERN& CHIEF CLINICIAN
Credential: LCPC, LPC
Phone: 301-895-3388