Provider Demographics
NPI:1366610099
Name:BLOOM, CAROL B (PT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:B
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:2214 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-3918
Mailing Address - Country:US
Mailing Address - Phone:608-784-6970
Mailing Address - Fax:608-784-6970
Practice Address - Street 1:2214 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-3918
Practice Address - Country:US
Practice Address - Phone:608-784-6970
Practice Address - Fax:608-784-6970
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1231-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40062700Medicaid