Provider Demographics
NPI:1104900117
Name:BLOOMINGDALE, HELENA (LICSW)
Entity type:Individual
Prefix:
First Name:HELENA
Middle Name:
Last Name:BLOOMINGDALE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:HELENA
Other - Middle Name:ZS
Other - Last Name:BLOOMINGDALE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:101 BOSTON AVE # 2
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 BOSTON AVE # 2
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3570
Practice Address - Country:US
Practice Address - Phone:617-710-1368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1144361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP24111Medicare PIN