Healthcare Provider Details

I. General information

NPI: 1396533600
Provider Name (Legal Business Name): BLOOMWELL BEHAVIORAL HEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2829 N 90TH ST
OMAHA NE
68134-5774
US

IV. Provider business mailing address

382 NE 191ST ST STE 98090
MIAMI FL
33179-3899
US

V. Phone/Fax

Practice location:
  • Phone: 401-819-4059
  • Fax: 919-561-6112
Mailing address:
  • Phone: 612-201-2468
  • Fax: 919-561-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: LOGAN PRATT
Title or Position: CEO
Credential:
Phone: 612-201-2468