Provider Demographics
NPI:1487678207
Name:BLOOM, RICHARD (MFT)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:BLOOM
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 W SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-4281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:865 3RD ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4515
Practice Address - Country:US
Practice Address - Phone:707-665-0846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC19312106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist