Provider Demographics
NPI:1174530661
Name:BLOOM, LINDA (PHD)
Entity type:Individual
Prefix:
First Name:LINDA
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 1:330 S WHITNEY WAY
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4638
Mailing Address - Country:US
Mailing Address - Phone:608-231-3191
Mailing Address - Fax:608-231-3108
Practice Address - Street 1:330 S WHITNEY WAY
Practice Address - Street 2:SUITE 304
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4638
Practice Address - Country:US
Practice Address - Phone:608-231-3191
Practice Address - Fax:608-231-3108
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI990-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38047900Medicaid
WI 1766001Medicare PIN