Healthcare Provider Details

I. General information

NPI: 1730161910
Provider Name (Legal Business Name): ROBERT BLOOM PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5384 POPLAR AVE SUITE 313
MEMPHIS TN
38119-3609
US

IV. Provider business mailing address

PO BOX 579
OLIVE BRANCH MS
38654-0579
US

V. Phone/Fax

Practice location:
  • Phone: 901-521-9671
  • Fax:
Mailing address:
  • Phone: 662-895-1707
  • Fax: 662-893-0388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP0376
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number04-4P
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: