Provider Demographics
NPI:1477679363
Name:BLOOM, MELISSA MARIE (PHD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:BLOOM
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 1:1700 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-2918
Mailing Address - Country:US
Mailing Address - Phone:415-292-1500
Mailing Address - Fax:415-292-2030
Practice Address - Street 1:1700 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-2918
Practice Address - Country:US
Practice Address - Phone:415-292-1500
Practice Address - Fax:415-292-2030
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15832103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11062OtherCBHS INTERNAL USE ONLY-COMMERCIAL NUMBER
11062OtherSFGH INTERNAL USE ONLY