Healthcare Provider Details

I. General information

NPI: 1609782069
Provider Name (Legal Business Name): BLOOM INTEGRATIVE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W BOBWHITE CT STE 225
BOISE ID
83706-6601
US

IV. Provider business mailing address

9169 W STATE ST STE 486
GARDEN CITY ID
83714-1733
US

V. Phone/Fax

Practice location:
  • Phone: 208-495-4068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JUSTINE GRAHAM-HERBERT
Title or Position: OWNER
Credential: LCPC
Phone: 208-495-4068