Basic Information
| Provider Information | |||||||||
| NPI: | 1164660551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.ED., NCC, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 S MADISON BLVD | ||||||||
| Address2: | SUITE C1 | ||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275735485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365998366 | ||||||||
| FaxNumber: | 3363226168 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 S MADISON BLVD | ||||||||
| Address2: | SUITE C1 | ||||||||
| City: | ROXBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275735485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365998366 | ||||||||
| FaxNumber: | 3363226168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 01/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 7282 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.