Provider Demographics
NPI:1699920314
Name:BLOOM, MARSTON LLOYD (PHD)
Entity type:Individual
Prefix:DR
First Name:MARSTON
Middle Name:LLOYD
Last Name:BLOOM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BECKY CT
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94949-5470
Mailing Address - Country:US
Mailing Address - Phone:574-780-6483
Mailing Address - Fax:
Practice Address - Street 1:250 BEL MARIN KEYS BLVD
Practice Address - Street 2:C-5
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-5727
Practice Address - Country:US
Practice Address - Phone:574-780-6483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14482103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist