Healthcare Provider Details

I. General information

NPI: 1023923778
Provider Name (Legal Business Name): BLOOMSTATE MENTAL HEALTH, A NURSING PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23811 WASHINGTON AVE #C-110 #140
MURRIETA CA
92562
US

IV. Provider business mailing address

23811 WASHINGTON AVE #C-110 #140
MURRIETA CA
92562
US

V. Phone/Fax

Practice location:
  • Phone: 951-200-9734
  • Fax:
Mailing address:
  • Phone: 951-200-9734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SARAH DEWOLF
Title or Position: CEO
Credential: MSN, APRN, PMHNP-BC
Phone: 951-200-9734