Provider Demographics
NPI:1417575390
Name:BLOOM, MELISSA ANNE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 JOSEPH ST UNIT 7R
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3959
Mailing Address - Country:US
Mailing Address - Phone:561-445-3632
Mailing Address - Fax:
Practice Address - Street 1:7 JOSEPH ST # 7R
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3959
Practice Address - Country:US
Practice Address - Phone:617-863-7162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC10001646101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health