Provider Demographics
NPI:1538119912
Name:BLOM, STANLEY WAYNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:WAYNE
Last Name:BLOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:STAN
Other - Middle Name:
Other - Last Name:BLOM, PH.D., INC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:150 W ANGELA BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1101
Mailing Address - Country:US
Mailing Address - Phone:574-251-1286
Mailing Address - Fax:574-232-5386
Practice Address - Street 1:150 W ANGELA BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1101
Practice Address - Country:US
Practice Address - Phone:574-251-1286
Practice Address - Fax:574-232-5386
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040666A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200008720Medicaid
IN162590Medicare ID - Type Unspecified