Provider Demographics
NPI:1063540698
Name:BLOOM, VICTORIA (PHD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name: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 1:218A 19TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-3906
Mailing Address - Country:US
Mailing Address - Phone:949-474-8494
Mailing Address - Fax:
Practice Address - Street 1:19742 MACARTHUR BLVD
Practice Address - Street 2:115
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2432
Practice Address - Country:US
Practice Address - Phone:949-474-8494
Practice Address - Fax:714-969-4757
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14866103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical