Healthcare Provider Details

I. General information

NPI: 1174176366
Provider Name (Legal Business Name): BLOOM BEHAVIORAL HEALTH PARTNERS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 WEALTHY ST SE STE 242
GRAND RAPIDS MI
49506-2755
US

IV. Provider business mailing address

1514 WEALTHY ST SE STE 242
GRAND RAPIDS MI
49506-2755
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-2138
  • Fax: 616-228-8990
Mailing address:
  • Phone: 616-202-2138
  • Fax: 616-228-8990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW THATCHER
Title or Position: OWNER / COUNSELOR
Credential: L.P.C.
Phone: 616-202-2138