Provider Demographics
NPI:1982791216
Name:REBECCA J BLOOMGARDEN INC
Entity type:Organization
Organization Name:REBECCA J BLOOMGARDEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLOOMGARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-692-3015
Mailing Address - Street 1:10400 GREENBRIAR PL
Mailing Address - Street 2:SUITE 104
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7637
Mailing Address - Country:US
Mailing Address - Phone:405-692-3015
Mailing Address - Fax:
Practice Address - Street 1:10400 GREENBRIAR PL
Practice Address - Street 2:SUITE 104
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7637
Practice Address - Country:US
Practice Address - Phone:405-692-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK315482873-001OtherBC/BS OF OKLA