Provider Demographics
NPI:1720144306
Name:BLOOM, PETER (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
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 1:1707 BELLE VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307-6727
Mailing Address - Country:US
Mailing Address - Phone:703-765-5675
Mailing Address - Fax:703-765-6115
Practice Address - Street 1:1707 BELLE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307-6727
Practice Address - Country:US
Practice Address - Phone:703-765-5675
Practice Address - Fax:703-765-6115
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000667103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical