Provider Demographics
NPI:1073163580
Name:MICHAEL V BLOOM PHD LLC
Entity Type:Organization
Organization Name:MICHAEL V BLOOM PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:269-345-0669
Mailing Address - Street 1:PO BOX 3272
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48605-3272
Mailing Address - Country:US
Mailing Address - Phone:989-797-1400
Mailing Address - Fax:989-797-4077
Practice Address - Street 1:7920 KIRKLAND CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4974
Practice Address - Country:US
Practice Address - Phone:269-345-0669
Practice Address - Fax:269-345-5354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-17
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301017079OtherSTATE LICENSE