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General NPI Number Information
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NPI Number | 1073824991
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Entity Type | Organization
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Legal Business Name | BLOOM COUNSELING, PC
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Dates
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Enumeration Date | 06/25/2010
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Last Update Date | 06/29/2010
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Provider Practice Location Address
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Address Line | 3113 WOODSIDE DR
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City | ARDMORE
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State | OK
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Zip | 73401-9118
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Country | US
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Telephone | 580-222-7023
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Fax |
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Provider Business Mailing Address
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Address Line | 3113 WOODSIDE DR
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City | ARDMORE
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State | OK
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Zip | 73401-9118
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Country | US
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Telephone | 580-222-7023
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MATTHEW W BLOOM
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Credential | LPC
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Telephone | 580-222-7023
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4312
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License Number State | OK
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