Provider Demographics
NPI:1063729887
Name:BLOOM, DIANE ATLAGIC (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ATLAGIC
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 187
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12786-0001
Mailing Address - Country:US
Mailing Address - Phone:917-921-5420
Mailing Address - Fax:
Practice Address - Street 1:37 BREAKEY AVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-4268
Practice Address - Country:US
Practice Address - Phone:845-794-0128
Practice Address - Fax:847-794-0250
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019518235Z00000X
NY019518-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist