Provider Demographics
NPI:1811910656
Name:BLOM, BERNHARD EMILE (PHD)
Entity type:Individual
Prefix:DR
First Name:BERNHARD
Middle Name:EMILE
Last Name:BLOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Mailing Address - Street 1:725 N MIDLOTHIAN RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1255
Mailing Address - Country:US
Mailing Address - Phone:224-610-3234
Mailing Address - Fax:224-610-3869
Practice Address - Street 1:3001 GREEN BAY RD
Practice Address - Street 2:PSYCHOLOGY SERVICE, VA MEDICAL CENTER (116B)
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064
Practice Address - Country:US
Practice Address - Phone:224-610-3234
Practice Address - Fax:224-610-3869
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical