Healthcare Provider Details

I. General information

NPI: 1619791936
Provider Name (Legal Business Name): BRAVE BLOOMS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 NW BAKER DR
ADRIAN MO
64720-2000
US

IV. Provider business mailing address

1087 NW BAKER DR
ADRIAN MO
64720-2000
US

V. Phone/Fax

Practice location:
  • Phone: 816-803-4898
  • Fax:
Mailing address:
  • Phone: 816-803-4898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. TIFFANY HENDRICKS
Title or Position: THERAPIST
Credential: LCSW
Phone: 816-803-4898