Healthcare Provider Details

I. General information

NPI: 1154187193
Provider Name (Legal Business Name): BLOOM HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3184 RIVER VALLEY CHASE
WEST FRIENDSHIP MD
21794-9542
US

IV. Provider business mailing address

3375 ELLICOTT CENTER DR #697
ELLICOTT CITY MD
21041
US

V. Phone/Fax

Practice location:
  • Phone: 443-457-0699
  • Fax: 917-268-9786
Mailing address:
  • Phone: 443-457-0699
  • Fax: 917-268-9786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL LEVITICUS WILLIAMS III
Title or Position: CEO AND FOUNDER
Credential: MD, MBA
Phone: 443-457-0699