Provider Demographics
NPI:1730892365
Name:BLOOM, KELSEY L (LCSW)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:L
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:PO BOX 748519
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8519
Mailing Address - Country:US
Mailing Address - Phone:904-376-3800
Mailing Address - Fax:
Practice Address - Street 1:30 ARDISIA LN
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-3881
Practice Address - Country:US
Practice Address - Phone:904-376-3800
Practice Address - Fax:904-390-7458
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW202161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical