Provider Demographics
NPI:1316588833
Name:BLOOMFIELD, CORBEN P (LPC)
Entity type:Individual
Prefix:DR
First Name:CORBEN
Middle Name:P
Last Name:BLOOMFIELD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2914 PAINTED PONY LN
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-6444
Mailing Address - Country:US
Mailing Address - Phone:208-880-2410
Mailing Address - Fax:
Practice Address - Street 1:8340 MEADOW RD STE 134
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4280
Practice Address - Country:US
Practice Address - Phone:214-265-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-06
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68794101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty