Provider Demographics
NPI:1396884789
Name:WOLF-BLOOM, MICHELLE S (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:S
Last Name:WOLF-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 1:275 HOSPITAL PKWY
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 HOSPITAL PKWY
Practice Address - Street 2:SUITE 600
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1106
Practice Address - Country:US
Practice Address - Phone:408-972-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16688103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY16688OtherPSYCHOLOGIST LICENSE