Provider Demographics
NPI:1417001116
Name:BLOOM, DOUGLAS RANDAL (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:RANDAL
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 1:6621 FANNIN ST
Mailing Address - Street 2:CCC 1630.00
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2303
Mailing Address - Country:US
Mailing Address - Phone:832-822-3700
Mailing Address - Fax:832-825-4164
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:CCC 1630.00
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2303
Practice Address - Country:US
Practice Address - Phone:832-822-3700
Practice Address - Fax:832-825-4164
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25782103T00000X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1027542-03Medicaid