Provider Demographics
NPI:1699236190
Name:BLOOM, SAMANTHA MARGARET (MFT INTERN)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MARGARET
Last Name:BLOOM
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1453 EVENING SONG AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89012-4465
Mailing Address - Country:US
Mailing Address - Phone:847-346-9785
Mailing Address - Fax:
Practice Address - Street 1:2920 N GREEN VALLEY PKWY STE 321
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-0412
Practice Address - Country:US
Practice Address - Phone:702-825-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMI1154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist