Provider Demographics
NPI:1871641282
Name:BLOOM, RICHARD KENNETH (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:KENNETH
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1369 CROWN DR # 11
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3727
Mailing Address - Country:US
Mailing Address - Phone:510-334-9373
Mailing Address - Fax:510-724-5304
Practice Address - Street 1:1369 CROWN DR
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-3727
Practice Address - Country:US
Practice Address - Phone:510-334-9373
Practice Address - Fax:510-724-5304
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8494103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL84940Medicare PIN