Provider Demographics
NPI:1447050919
Name:BLOOM, MADISON (BS)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BLOOM
Suffix:
Gender:
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1578 NE GOOSEBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LEE
Mailing Address - State:FL
Mailing Address - Zip Code:32059-4469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1578 NE GOOSEBERRY ST
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:FL
Practice Address - Zip Code:32059-4469
Practice Address - Country:US
Practice Address - Phone:386-466-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker