Healthcare Provider Details

I. General information

NPI: 1104376821
Provider Name (Legal Business Name): KRYSTLE MICHELLE BLOOM PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W CARSON ST
TORRANCE CA
90502-2004
US

IV. Provider business mailing address

PO BOX 15682
LONG BEACH CA
90815-0682
US

V. Phone/Fax

Practice location:
  • Phone: 310-222-3151
  • Fax:
Mailing address:
  • Phone: 562-505-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY33827
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: