Healthcare Provider Details

I. General information

NPI: 1063129286
Provider Name (Legal Business Name): CYNTHIA BLOOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 W 96TH ST STE A
BLOOMINGTON MN
55431-2657
US

IV. Provider business mailing address

1216 W 96TH ST STE A
BLOOMINGTON MN
55431-2657
US

V. Phone/Fax

Practice location:
  • Phone: 952-884-4882
  • Fax:
Mailing address:
  • Phone: 952-884-4882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC02855
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: