Provider Demographics
NPI:1730161910
Name:BLOOM, ROBERT (PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 579
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-0579
Mailing Address - Country:US
Mailing Address - Phone:662-895-1707
Mailing Address - Fax:662-893-0388
Practice Address - Street 1:5384 POPLAR AVE
Practice Address - Street 2:SUITE 313
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3609
Practice Address - Country:US
Practice Address - Phone:901-521-9671
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0376103TC0700X
AR04-4P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6382759Medicare ID - Type Unspecified