Provider Demographics
NPI:1154332567
Name:BLOOM, ALLAN ALBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:ALBERT
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 1:4000 BLUE RIDGE RD
Mailing Address - Street 2:SUITE 380
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4650
Mailing Address - Country:US
Mailing Address - Phone:919-787-7307
Mailing Address - Fax:919-787-8414
Practice Address - Street 1:4000 BLUE RIDGE RD
Practice Address - Street 2:SUITE 380
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4650
Practice Address - Country:US
Practice Address - Phone:919-787-7307
Practice Address - Fax:919-787-8414
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1519103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2814029Medicare ID - Type Unspecified