Basic Information
| Provider Information | |||||||||
| NPI: | 1184917361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLOOM | ||||||||
| FirstName: | ZACHARY | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 DUNSTEN CIR | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472040943 | ||||||||
| FaxNumber: | 8475098452 | ||||||||
| Practice Location | |||||||||
| Address1: | 3633 WEST LAKE AVE | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472040943 | ||||||||
| FaxNumber: | 4075224671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2011 | ||||||||
| LastUpdateDate: | 05/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 166001123 | IL | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | 180.010958 | IL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.