Healthcare Provider Details

I. General information

NPI: 1770709834
Provider Name (Legal Business Name): MELISSA SHEA BLOOM D.P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 FAIRMOUNT AVE STE 530
TOWSON MD
21286-5466
US

IV. Provider business mailing address

617 W 40TH ST
BALTIMORE MD
21211-2219
US

V. Phone/Fax

Practice location:
  • Phone: 410-296-0680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number27092
License Number StateMD

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: