Provider Demographics
NPI:1437247012
Name:BLOOS, MELINDA LUANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELINDA
Middle Name:LUANNE
Last Name:BLOOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N WOOD RD
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-6290
Mailing Address - Country:US
Mailing Address - Phone:618-457-6443
Mailing Address - Fax:618-351-1419
Practice Address - Street 1:1400 N WOOD RD
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-6290
Practice Address - Country:US
Practice Address - Phone:618-457-6443
Practice Address - Fax:618-351-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071004937103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL237890Medicare ID - Type Unspecified