MEDICARE: MR. DAVID JONATHAN BLEECKER PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	20040212	IN

General Provider Information

NPI Number	:	1376551242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID JONATHAN BLEECKER PHD

Provider Business Mailing Address
First Line	:	4217 EAST PENN COURT
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47408-3124
Country	:	US
Telephone Number	:	812-332-8975
Fax Number	:

Provider Business Practice Location Address
First Line	:	627 NORTH MORTON ST
Second Line	:	STE 202
City	:	BLOOMINGTON
State	:	IN
Zip	:	47404-3750
Country	:	US
Telephone Number	:	812-323-2061
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/08/2007

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