Healthcare Provider Details

I. General information

NPI: 1386549517
Provider Name (Legal Business Name): BLOOM & TIDE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 KILRUSH RD
CLEMMONS NC
27012-7914
US

IV. Provider business mailing address

1809 KILRUSH RD
CLEMMONS NC
27012-7914
US

V. Phone/Fax

Practice location:
  • Phone: 336-830-7944
  • Fax:
Mailing address:
  • Phone: 336-830-7944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: SANDRA LEA SWINDLE
Title or Position: MEMBER AND ORGANIZER
Credential: LCMHC, MA
Phone: 336-830-7944