Provider Demographics
NPI:1316983380
Name:BLOOMGARDEN, ANDREA L (PH D)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:L
Last Name:BLOOMGARDEN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:709 S MILDRED ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-2041
Mailing Address - Country:US
Mailing Address - Phone:215-545-1175
Mailing Address - Fax:215-592-4190
Practice Address - Street 1:230 S BROAD ST STE 1305
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4104
Practice Address - Country:US
Practice Address - Phone:215-545-1175
Practice Address - Fax:215-592-4190
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012038 1103TC0700X
DEB10000498103TC0700X
PAPS 006943 L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128973000OtherKEYSTONE
0007732066OtherAETNA
156288000OtherMAGELLAN
2128973000OtherPERSONAL CHOICE
2128973000OtherIBC
1471004OtherHIGHMARK BLUE CROSS PPO