Provider Demographics
NPI:1316343536
Name:BLOOM, KATIE M (LCSW-PIP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:M
Last Name:BLOOM
Suffix:
Gender:F
Credentials:LCSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4527
Mailing Address - Country:US
Mailing Address - Phone:605-338-3639
Mailing Address - Fax:
Practice Address - Street 1:1710 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4527
Practice Address - Country:US
Practice Address - Phone:605-338-3639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-16
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD31311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical