Basic Information
| Provider Information | |||||||||
| NPI: | 1558641910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | RITA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REIBLE | ||||||||
| OtherFirstName: | JILL | ||||||||
| OtherMiddleName: | RITA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 202 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6084176000 | ||||||||
| FaxNumber: | 6084176687 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 S PARK STREET | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WISCONSIN | ||||||||
| PostalCode: | 537151507 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 6084176173 | ||||||||
| FaxNumber: | 6084176687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2011 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 3530-154 | WI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.