Healthcare Provider Details

I. General information

NPI: 1124800776
Provider Name (Legal Business Name): BLOOM HAVEN BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8206 LOUISIANA BLVD NE STE A
ALBUQUERQUE NM
87113-1738
US

IV. Provider business mailing address

1380 RIO RANCHO BLVD SE
RIO RANCHO NM
87124-1006
US

V. Phone/Fax

Practice location:
  • Phone: 505-900-4029
  • Fax: 505-212-2300
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LISA LUJAN
Title or Position: OWNER
Credential:
Phone: 505-916-4729