Provider Demographics
NPI:1487948972
Name:BLOOM, AUDREY (LCSW)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17142 SW 112TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3907
Mailing Address - Country:US
Mailing Address - Phone:305-301-8251
Mailing Address - Fax:
Practice Address - Street 1:2000 S DIXIE HWY
Practice Address - Street 2:SUITE 104, COCONUT GROVE CENTER
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-2456
Practice Address - Country:US
Practice Address - Phone:305-301-8251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical