Provider Demographics
NPI:1972974350
Name:BLOOM, ALISHA ROSE (PSY D)
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:ROSE
Last Name:BLOOM
Suffix:
Gender:F
Credentials:PSY D
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DRIVE
Mailing Address - Street 2:SAN ANTONIO MILITARY MEDICAL CENTER DEPT BEHAV MED
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-539-6150
Mailing Address - Fax:210-539-5467
Practice Address - Street 1:9040A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-4504
Practice Address - Country:US
Practice Address - Phone:253-968-6067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY617103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX39020000XOtherSTUDENT IN AN ORGANIZED HEALTHCARE EDUCATION/ TRAINING PROGRAM