Provider Demographics
NPI:1184917361
Name:BLOOM, ZACHARY D (PHD)
Entity type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:D
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 DUNSTEN CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062
Mailing Address - Country:US
Mailing Address - Phone:847-204-0943
Mailing Address - Fax:847-509-8452
Practice Address - Street 1:3633 WEST LAKE AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026
Practice Address - Country:US
Practice Address - Phone:847-204-0943
Practice Address - Fax:407-522-4671
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166001123106H00000X
IL180.010958101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health