Provider Demographics
NPI:1902636665
Name:BLOOM, MINDY E
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:E
Last Name:BLOOM
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 1:10604 NE HIGHWAY 99
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-5613
Mailing Address - Country:US
Mailing Address - Phone:360-644-1631
Mailing Address - Fax:
Practice Address - Street 1:10604 NE HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-5613
Practice Address - Country:US
Practice Address - Phone:360-644-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor