Healthcare Provider Details

I. General information

NPI: 1215702311
Provider Name (Legal Business Name): BLOOM BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W 2ND ST STE 150H
DULUTH MN
55802-1920
US

IV. Provider business mailing address

205 W 2ND ST STE 150H
DULUTH MN
55802-1920
US

V. Phone/Fax

Practice location:
  • Phone: 218-606-0819
  • Fax:
Mailing address:
  • Phone: 218-606-0819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: JOSH MCILRATH
Title or Position: OWNER/PARTNER
Credential:
Phone: 218-606-0819