Individual
DR. STANLEY WAYNE BLOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PH.D.
Contact information
Practice address
150 W ANGELA BLVD, SOUTH BEND, IN 46617-1101
(574) 251-1286
(574) 232-5386
Mailing address
150 W ANGELA BLVD, SOUTH BEND, IN 46617-1101
(574) 251-1286
(574) 232-5386
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
20040666A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200008720
—
IN
Enumeration date
05/10/2006
Last updated
08/12/2019
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