Provider Demographics
NPI:1083627947
Name:BLOOM, WILLIAM (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
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 1:2855 COOLIDGE HIGHWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-649-9202
Mailing Address - Fax:248-649-8922
Practice Address - Street 1:2855 COOLIDGE HIGHWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-649-9202
Practice Address - Fax:248-649-8922
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006833103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI620F34877OtherBCBS
MI0F34877Medicare ID - Type Unspecified