Healthcare Provider Details

I. General information

NPI: 1174222624
Provider Name (Legal Business Name): AUDREY BLOOM LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11651 26TH AVE SW
BURIEN WA
98146-2402
US

IV. Provider business mailing address

2003 D ST STE 100
BELLINGHAM WA
98225-3204
US

V. Phone/Fax

Practice location:
  • Phone: 734-395-0565
  • Fax:
Mailing address:
  • Phone: 734-395-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH61654296
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: