Provider Demographics
NPI:1770596587
Name:CHILDRENS ORTHOGENIC INSTITUTE
Entity type:Organization
Organization Name:CHILDRENS ORTHOGENIC INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-649-9202
Mailing Address - Street 1:2855 COOLIDGE HIGHWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084
Mailing Address - Country:US
Mailing Address - Phone:248-649-9202
Mailing Address - Fax:248-649-8922
Practice Address - Street 1:2855 COOLIDGE HIGHWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084
Practice Address - Country:US
Practice Address - Phone:248-649-9202
Practice Address - Fax:248-649-8922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006833103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty