Provider Demographics
NPI:1487064960
Name:BLOOM-RAU, ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BLOOM-RAU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CLAVENDON CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-3533
Mailing Address - Country:US
Mailing Address - Phone:908-239-8076
Mailing Address - Fax:
Practice Address - Street 1:210 W FRONT ST
Practice Address - Street 2:SUITE 206A
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1155
Practice Address - Country:US
Practice Address - Phone:908-239-8076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SLO5829400104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker