Basic Information
| Provider Information | |||||||||
| NPI: | 1700144060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | ELENA | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 LAC DU MONT APT C2 | ||||||||
| Address2: | |||||||||
| City: | HASLETT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488409518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192441913 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2814 WOODCLIFF CIR SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495063155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-12-10114 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.