Healthcare Provider Details

I. General information

NPI: 1396989141
Provider Name (Legal Business Name): SUSAN JONE BLOOM PSY. D., APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 N JACKSON ST STE 510
MILWAUKEE WI
53202-4697
US

IV. Provider business mailing address

731 N JACKSON ST STE 510
MILWAUKEE WI
53202-4697
US

V. Phone/Fax

Practice location:
  • Phone: 847-372-9612
  • Fax: 888-266-8068
Mailing address:
  • Phone: 847-372-9612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041-205215
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number209-006444
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5697
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5697
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: