Provider Demographics
NPI:1124196985
Name:ROSENBLOOM, RAY M (PHD)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:M
Last Name:ROSENBLOOM
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 1:1810 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-4224
Mailing Address - Country:US
Mailing Address - Phone:512-983-6816
Mailing Address - Fax:512-858-2053
Practice Address - Street 1:1114 LOST CREEK BLVD STE 320
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-983-6816
Practice Address - Fax:512-858-2053
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002325103TC0700X
TX33167103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11287287OtherCAQH
MI620F34837OtherBLUE CROSS BLUE SHIELD MI
MI620F34837OtherBLUE CROSS BLUE SHIELD MI