Provider Demographics
NPI:1407878051
Name:BLOOM, LARRY JAY (PHD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JAY
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 1:1000 SOUTHPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5654
Mailing Address - Country:US
Mailing Address - Phone:303-715-2264
Mailing Address - Fax:303-703-2118
Practice Address - Street 1:OF PSYCHOLOGY COLORADO STATE UNIVERSITY
Practice Address - Street 2:
Practice Address - City:FT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-0001
Practice Address - Country:US
Practice Address - Phone:970-491-5214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO500103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service