Provider Demographics
NPI:1124357306
Name:BLOOM, ALEX (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3380
Mailing Address - Country:US
Mailing Address - Phone:541-868-2004
Mailing Address - Fax:541-868-2003
Practice Address - Street 1:8285 SW NIMBUS AVE STE 130
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6428
Practice Address - Country:US
Practice Address - Phone:503-610-2044
Practice Address - Fax:503-296-2102
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2330103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
R0000WDBCHOtherMEDICARE GROUP