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General NPI Number Information
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NPI Number | 1558895003
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Entity Type | Organization
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Legal Business Name | GWEN S. BLOOM LCSW LLC
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Dates
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Enumeration Date | 04/11/2017
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Last Update Date | 03/02/2018
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Provider Practice Location Address
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Address Line | 3322 ROUTE 22 SUITE 428
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City | BRANCHBURG
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State | NJ
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Zip | 08876-3476
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Country | US
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Telephone | 732-501-5917
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Fax |
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Provider Business Mailing Address
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Address Line | 21 KINGSWOOD RD
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City | BRANCHBURG
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State | NJ
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Zip | 08876-7428
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Country | US
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Telephone | 732-501-5917
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GWEN SUSAN BLOOM
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Credential | LCSW
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Telephone | 732-501-5917
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 44SC05137300
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License Number State | NJ
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