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NPI Code Detail

MEDICARE: AMANDA JEANNINE BLOOM

MEDICARE: AMANDA JEANNINE BLOOM
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
1101YM0800XMental Health Counselor60969266WA

General Provider Information

NPI Number : 1639739402
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA JEANNINE BLOOM
Provider Business Mailing Address
First Line : 3107 S DEARBORN ST
Second Line :
City : SEATTLE
State : WA
Zip : 98144-3228
Country : US
Telephone Number : 360-223-2073
Fax Number :
Provider Business Practice Location Address
First Line : 3107 S DEARBORN ST
Second Line :
City : SEATTLE
State : WA
Zip : 98144-3228
Country : US
Telephone Number : 360-223-2073
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/14/2019
Last Update Date : 06/14/2019

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Directions to “ AMANDA JEANNINE BLOOM ” Practice Location

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