Provider Demographics
NPI:1861967713
Name:VICTORIA BLOM LCSW LLC
Entity type:Organization
Organization Name:VICTORIA BLOM LCSW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:V
Authorized Official - Last Name:BLOM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:413-885-5763
Mailing Address - Street 1:318 MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1181
Mailing Address - Country:US
Mailing Address - Phone:413-885-5763
Mailing Address - Fax:
Practice Address - Street 1:318 MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1181
Practice Address - Country:US
Practice Address - Phone:413-885-5763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health