Healthcare Provider Details

I. General information

NPI: 1184573024
Provider Name (Legal Business Name): BLOOM TRAUMA THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2026
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 MOON ST NE APT 2233
ALBUQUERQUE NM
87111-1456
US

IV. Provider business mailing address

6001 MOON ST NE APT 2233
ALBUQUERQUE NM
87111-1456
US

V. Phone/Fax

Practice location:
  • Phone: 505-461-0935
  • Fax: 505-386-1776
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SARAI PEGUERO
Title or Position: LPC
Credential: MA
Phone: 505-461-0935