Healthcare Provider Details

I. General information

NPI: 1326536186
Provider Name (Legal Business Name): REBECCA BLOOM LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 HAMBURG TPKE FL 4
WAYNE NJ
07470-4032
US

IV. Provider business mailing address

380 FOOTHILL RD
BRIDGEWATER NJ
08807-2255
US

V. Phone/Fax

Practice location:
  • Phone: 908-585-1662
  • Fax:
Mailing address:
  • Phone: 973-994-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00826900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00404600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: