Healthcare Provider Details

I. General information

NPI: 1700797370
Provider Name (Legal Business Name): PHOENIX BLOOM THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
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

VIII. Authorized Official

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