Provider Demographics
NPI:1215487533
Name:BLOOM, AMY (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-9655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1734 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-9655
Practice Address - Country:US
Practice Address - Phone:252-635-1788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16655225100000X
AK120733225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist