MEDICARE: KATIE M BLOOM LCSW-PIP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	3131	SD

General Provider Information

NPI Number	:	1316343536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE M BLOOM LCSW-PIP

Provider Business Mailing Address
First Line	:	1710 W 18TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57104-4527
Country	:	US
Telephone Number	:	605-338-3639
Fax Number	:

Provider Business Practice Location Address
First Line	:	1710 W 18TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57104-4527
Country	:	US
Telephone Number	:	605-338-3639
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2014
Last Update Date	:	11/16/2014

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