Healthcare Provider Details

I. General information

NPI: 1942164843
Provider Name (Legal Business Name): NEUROBLOOM BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 BERRIEDALE DR
FAYETTEVILLE NC
28304-5503
US

IV. Provider business mailing address

1516 BERRIEDALE DR
FAYETTEVILLE NC
28304-5503
US

V. Phone/Fax

Practice location:
  • Phone: 910-545-7561
  • Fax:
Mailing address:
  • Phone: 910-545-7561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE STAR HOLZWORTH
Title or Position: RBT
Credential:
Phone: 910-545-7561