Healthcare Provider Details

I. General information

NPI: 1548532617
Provider Name (Legal Business Name): DOUGLASS R. BLOOMFIELD, PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 STAPLES MILL RD
RICHMOND VA
23228-5427
US

IV. Provider business mailing address

5821 STAPLES MILL RD
RICHMOND VA
23228-5427
US

V. Phone/Fax

Practice location:
  • Phone: 804-264-0966
  • Fax: 804-264-1029
Mailing address:
  • Phone: 804-264-0966
  • Fax: 804-264-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number0810000979
License Number StateVA

VIII. Authorized Official

Name: DR. DOUGLASS R BLOOMFIELD
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 804-264-0966