Healthcare Provider Details

I. General information

NPI: 1699663807
Provider Name (Legal Business Name): BLOOMING MENTAL HEALTH THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 16TH AVE S
FARGO ND
58103-4162
US

IV. Provider business mailing address

6730 72ND AVE S
HORACE ND
58047-9570
US

V. Phone/Fax

Practice location:
  • Phone: 701-429-4088
  • Fax:
Mailing address:
  • Phone: 701-429-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATRINA ANN DESCHENE
Title or Position: CEO
Credential: M.ED, LPCC
Phone: 701-429-4008