Healthcare Provider Details

I. General information

NPI: 1184917361
Provider Name (Legal Business Name): ZACHARY D. BLOOM PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WEST LAKE AVE SUITE 404
GLENVIEW IL
60026
US

IV. Provider business mailing address

621 DUNSTEN CIR
NORTHBROOK IL
60062
US

V. Phone/Fax

Practice location:
  • Phone: 847-204-0943
  • Fax: 407-522-4671
Mailing address:
  • Phone: 847-204-0943
  • Fax: 847-509-8452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.010958
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166001123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: