Provider Demographics
NPI:1396989141
Name:BLOOM, SUSAN JONE (PSY D, APNP)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JONE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PSY D, APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 N JACKSON ST
Mailing Address - Street 2:STE 510
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4697
Mailing Address - Country:US
Mailing Address - Phone:847-372-9612
Mailing Address - Fax:
Practice Address - Street 1:731 N JACKSON ST
Practice Address - Street 2:STE 510
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4697
Practice Address - Country:US
Practice Address - Phone:847-372-9612
Practice Address - Fax:888-266-8068
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-205215163W00000X
IL209-006444364SP0809X
WI5697363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner