Healthcare Provider Details

I. General information

NPI: 1285355610
Provider Name (Legal Business Name): BIONIC BLOOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2022
Last Update Date: 03/22/2026
Certification Date: 03/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13575 58TH ST N STE 203
CLEARWATER FL
33760-3740
US

IV. Provider business mailing address

2232 2ND AVE S UNIT 136
ST PETERSBURG FL
33712-1210
US

V. Phone/Fax

Practice location:
  • Phone: 727-490-9911
  • Fax:
Mailing address:
  • Phone: 727-490-9911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANGELA FISHER
Title or Position: CEO
Credential: PHD
Phone: 727-490-9911