Provider Demographics
NPI:1083470215
Name:BLOOM, MONICA HEATHER (LPCA)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:HEATHER
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7320 SW HUNZIKER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-2301
Mailing Address - Country:US
Mailing Address - Phone:503-778-0787
Mailing Address - Fax:541-631-6087
Practice Address - Street 1:7320 SW HUNZIKER RD STE 201
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-2301
Practice Address - Country:US
Practice Address - Phone:503-778-0787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8814101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500791700Medicaid