Healthcare Provider Details

I. General information

NPI: 1376148601
Provider Name (Legal Business Name): BLOOM COUNSELING AND THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2020
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16506 N DALE MABRY HWY
TAMPA FL
33618-1325
US

IV. Provider business mailing address

12011 CITRUS FALLS CIR APT 203
TAMPA FL
33625-5716
US

V. Phone/Fax

Practice location:
  • Phone: 813-262-0460
  • Fax:
Mailing address:
  • Phone:
  • 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: DANIELLE BLYDEN
Title or Position: FOUNDER
Credential: LCSW
Phone: 407-455-4425