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General NPI Number Information
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NPI Number | 1316240385
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Entity Type | Individual
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Provider Name | MICHELLE JORDANA BLOOM L.C.S.W.
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Gender | Female
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Dates
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Enumeration Date | 12/14/2010
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Last Update Date | 05/13/2015
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Provider Practice Location Address
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Address Line | 1651 3RD AVE SUITE 201
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City | NEW YORK
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State | NY
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Zip | 10128-3679
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Country | US
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Telephone | 516-526-7120
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Fax |
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Provider Business Mailing Address
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Address Line | 500 EAST 83RD STREET APT 4L
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City | NEW YORK
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State | NY
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Zip | 10028
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Country | US
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Telephone | 516-526-7120
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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 | 72 082712
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 73081585
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License Number State | NY
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