Provider Demographics
NPI:1144904855
Name:BLOM, MADELEINE LAUREN
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:LAUREN
Last Name:BLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 SOUTHWESTERN BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-1860
Mailing Address - Country:US
Mailing Address - Phone:716-884-0888
Mailing Address - Fax:716-855-4628
Practice Address - Street 1:4535 SOUTHWESTERN BLVD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-1860
Practice Address - Country:US
Practice Address - Phone:716-884-0888
Practice Address - Fax:716-855-4628
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator