Healthcare Provider Details

I. General information

NPI: 1285484204
Provider Name (Legal Business Name): BLOOM MENTAL HEALTH AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 INTERNATIONAL PKWY STE 2000
LAKE MARY FL
32746-5096
US

IV. Provider business mailing address

1540 INTERNATIONAL PKWY STE 2000
LAKE MARY FL
32746-5096
US

V. Phone/Fax

Practice location:
  • Phone: 407-554-9970
  • Fax:
Mailing address:
  • Phone: 407-252-7011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LARI J QUINTERO
Title or Position: OWNER
Credential: APRN
Phone: 407-252-7011