Healthcare Provider Details

I. General information

NPI: 1073322368
Provider Name (Legal Business Name): BLOOM COUNSELING OF SANFORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 REGIMENTAL DR
CAMERON NC
28326-7668
US

IV. Provider business mailing address

628 REGIMENTAL DR
CAMERON NC
28326-7668
US

V. Phone/Fax

Practice location:
  • Phone: 731-592-3351
  • Fax:
Mailing address:
  • Phone: 731-592-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY DENISE CASEY
Title or Position: OWNER/THERAPIST
Credential: LCMHC
Phone: 731-592-3351