Healthcare Provider Details

I. General information

NPI: 1013820992
Provider Name (Legal Business Name): PHOENIX BLOOM FAMILY FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 HIDEAWAY DR
COVINGTON KY
41017-9775
US

IV. Provider business mailing address

31 HIDEAWAY DR
COVINGTON KY
41017-9775
US

V. Phone/Fax

Practice location:
  • Phone: 859-307-4540
  • Fax:
Mailing address:
  • Phone: 859-307-4540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: TINA NICHOLE HACKER
Title or Position: DIRECTOR
Credential: LMFT, IMFT, LICDC
Phone: 859-307-4540