Healthcare Provider Details

I. General information

NPI: 1801738307
Provider Name (Legal Business Name): INTERNALLY BLOOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5004 S U ST STE 200
FORT SMITH AR
72903-3600
US

IV. Provider business mailing address

5004 S U ST STE 200
FORT SMITH AR
72903-3600
US

V. Phone/Fax

Practice location:
  • Phone: 479-888-8234
  • Fax: 479-888-8234
Mailing address:
  • Phone: 479-888-8234
  • Fax: 479-888-8234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LISA SISCO
Title or Position: OWNER/MANAGER/PROVIDER
Credential: LPC
Phone: 479-888-8234