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General NPI Number Information
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NPI Number | 1053530261
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Entity Type | Individual
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Provider Name | INGRID A BLOOM LICSW
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Gender | Female
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Dates
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Enumeration Date | 04/25/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 12 S 6TH ST #1137
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City | MINNEAPOLIS
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State | MN
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Zip | 55402
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Country | US
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Telephone | 612-722-7414
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Fax |
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Provider Business Mailing Address
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Address Line | 3637 46TH AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55406
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Country | US
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Telephone | 612-722-7414
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 01806
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License Number State | MN
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