Healthcare Provider Details

I. General information

NPI: 1689319444
Provider Name (Legal Business Name): BLOOM THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4366 RAMSGATE LN
BLOOMFIELD HILLS MI
48302-1638
US

IV. Provider business mailing address

4301 ORCHARD LAKE RD STE 180-147
WEST BLOOMFIELD MI
48323-1604
US

V. Phone/Fax

Practice location:
  • Phone: 517-420-0220
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LAUREN BLOOM
Title or Position: PSYCHOTHERAPIST/ BUSINESS OWNER
Credential: LMSW
Phone: 517-420-0220