Provider Demographics
NPI:1073652970
Name:BLOOM, MARLENE R (PHD)
Entity type:Individual
Prefix:DR
First Name:MARLENE
Middle Name:R
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 1:10909 MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2511
Mailing Address - Country:US
Mailing Address - Phone:813-864-1404
Mailing Address - Fax:
Practice Address - Street 1:10909 MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-2511
Practice Address - Country:US
Practice Address - Phone:813-864-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6043103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist