MEDICARE: KRISTIN BLOOMER ARCHDEACON LCSW

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	101YM0800X	Mental Health Counselor	LCSW80860	CA

General Provider Information

NPI Number	:	1427759406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN BLOOMER ARCHDEACON LCSW

Provider Business Mailing Address
First Line	:	55 S 14TH ST # 2
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95112-2016
Country	:	US
Telephone Number	:	408-829-2673
Fax Number	:

Provider Business Practice Location Address
First Line	:	725 E SANTA CLARA ST STE 105
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95112-1936
Country	:	US
Telephone Number	:	408-961-4645
Fax Number	:

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

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	03/15/2023

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Directions to “ KRISTIN BLOOMER ARCHDEACON LCSW” Practice Location

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