Healthcare Provider Details

I. General information

NPI: 1104617133
Provider Name (Legal Business Name): NEURO BLOOM THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2025
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 EXCELSIOR BLVD STE 50
ST LOUIS PARK MN
55416-4727
US

IV. Provider business mailing address

4100 EXCELSIOR BLVD STE 50
ST LOUIS PARK MN
55416-4727
US

V. Phone/Fax

Practice location:
  • Phone: 612-416-7520
  • Fax:
Mailing address:
  • Phone: 612-416-7520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: EFRAH MOHAMED
Title or Position: DIRECTOR
Credential:
Phone: 404-932-9111