Healthcare Provider Details

I. General information

NPI: 1376349043
Provider Name (Legal Business Name): BLOOM MINDFULLY COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 HARTFORD TPKE STE 104
VERNON CT
06066-4760
US

IV. Provider business mailing address

53 MEADOWLARK RD
VERNON CT
06066-4310
US

V. Phone/Fax

Practice location:
  • Phone: 860-248-6284
  • Fax:
Mailing address:
  • Phone: 860-248-6284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MACKENZIE PHELPS
Title or Position: OWNER/CLINICIAN
Credential: LCSW
Phone: 860-248-6284