Provider Demographics
NPI:1306179460
Name:BLOOM, STACI (PHD)
Entity type:Individual
Prefix:DR
First Name:STACI
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 1:7777 FOREST LN
Mailing Address - Street 2:SUITE B-326
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2505
Mailing Address - Country:US
Mailing Address - Phone:972-566-8466
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:SUITE B-326
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-8466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
38529OtherNATIONAL CERTIFICATION FOR SCHOOL PSYCHOLOGISTS