MEDICARE: MS. AUDREY BLOOM 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	1041C0700X	Clinical Social Worker	10388	FL

General Provider Information

NPI Number	:	1487948972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUDREY BLOOM LCSW

Provider Business Mailing Address
First Line	:	17142 SW 112TH CT
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33157-3907
Country	:	US
Telephone Number	:	305-301-8251
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 S DIXIE HWY
Second Line	:	SUITE 104, COCONUT GROVE CENTER
City	:	MIAMI
State	:	FL
Zip	:	33133-2456
Country	:	US
Telephone Number	:	305-301-8251
Fax Number	:

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

Provider Enumeration Date	:	06/02/2011
Last Update Date	:	06/02/2011

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