Provider Demographics
NPI:1104816644
Name:BLOOM, CAROLYN L (PT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:L
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:L
Other - Last Name:HAUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:4035 SW 10TH AVE
Practice Address - Street 2:TOPEKA
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-1916
Practice Address - Country:US
Practice Address - Phone:785-273-7700
Practice Address - Fax:785-273-7551
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1100373225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100003670BMedicaid
KS043207OtherBCBS PROVIDER NUMBER
KS059399OtherPROVIDER NUMBER
KS140007OtherBCBS PROVIDER NUMBER
KS650003470Medicare ID - Type UnspecifiedRRMEDICARE PROVIDER #
KS043207Medicare ID - Type UnspecifiedPROVIDER NUMBER