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General NPI Number Information
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NPI Number | 1730161910
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Entity Type | Individual
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Provider Name | ROBERT BLOOM PH.D.
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Gender | Male
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Dates
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Enumeration Date | 11/15/2005
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5384 POPLAR AVE SUITE 313
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City | MEMPHIS
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State | TN
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Zip | 38119-3609
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Country | US
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Telephone | 901-521-9671
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 579
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-0579
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Country | US
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Telephone | 662-895-1707
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Fax | 662-893-0388
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | P0376
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 04-4P
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License Number State | AR
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