Healthcare Provider Details

I. General information

NPI: 1578388799
Provider Name (Legal Business Name): BLOOM THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MAIN ST STE 6
STONEHAM MA
02180-2649
US

IV. Provider business mailing address

440 MAIN ST STE 6
STONEHAM MA
02180-2649
US

V. Phone/Fax

Practice location:
  • Phone: 574-212-2685
  • Fax:
Mailing address:
  • Phone: 574-212-2685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIRA BLOOM
Title or Position: LICSW
Credential: LICSW
Phone: 574-212-2685