Healthcare Provider Details

I. General information

NPI: 1356859466
Provider Name (Legal Business Name): LAURA LEE BLOOM NMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 10/13/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 NE 134TH ST STE 180C
VANCOUVER WA
98685-2799
US

IV. Provider business mailing address

7610 NE 142ND AVE
VANCOUVER WA
98682-4213
US

V. Phone/Fax

Practice location:
  • Phone: 360-450-5778
  • Fax: 833-992-2065
Mailing address:
  • Phone: 602-501-5491
  • Fax: 833-992-2066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number17-1681
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number4397
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number61015964
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: