Healthcare Provider Details

I. General information

NPI: 1376498345
Provider Name (Legal Business Name): BLOOM WELLNESS COLLECTIVE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4541 N PROSPECT RD STE 302
PEORIA HEIGHTS IL
61616-6490
US

IV. Provider business mailing address

4541 N PROSPECT RD STE 302
PEORIA HEIGHTS IL
61616-6490
US

V. Phone/Fax

Practice location:
  • Phone: 708-573-1955
  • Fax:
Mailing address:
  • Phone: 309-267-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DEVIN HENDERSON
Title or Position: MEMBER
Credential: LCSW
Phone: 309-267-6737