Healthcare Provider Details

I. General information

NPI: 1740901388
Provider Name (Legal Business Name): BLOOM THERAPY, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 03/03/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 UTICA RIDGE RD
BETTENDORF IA
52722-1616
US

IV. Provider business mailing address

3350 UTICA RIDGE RD
BETTENDORF IA
52722-1616
US

V. Phone/Fax

Practice location:
  • Phone: 563-265-5063
  • Fax: 877-583-4958
Mailing address:
  • Phone: 563-265-5063
  • Fax: 877-583-4958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ZACHERY NIELSEN
Title or Position: OWNER
Credential: LMHC, NCC
Phone: 563-265-5063