Healthcare Provider Details

I. General information

NPI: 1700144060
Provider Name (Legal Business Name): GABRIELLE ELENA BLOOM BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 WOODCLIFF CIR SE
GRAND RAPIDS MI
49506-3155
US

IV. Provider business mailing address

2102 LAC DU MONT APT C2
HASLETT MI
48840-9518
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax: 772-675-9100
Mailing address:
  • Phone: 619-244-1913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-10114
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: