Healthcare Provider Details

I. General information

NPI: 1215500921
Provider Name (Legal Business Name): BLOOM FLOURISH MENTAL HEALTH COUNSELING, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 LOCUST AVE
BABYLON NY
11702-2207
US

IV. Provider business mailing address

16 WILKEN LN
BRENTWOOD NY
11717-7515
US

V. Phone/Fax

Practice location:
  • Phone: 631-683-8072
  • Fax: 631-498-4952
Mailing address:
  • Phone: 631-683-8072
  • Fax: 631-498-4952

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: TATIANA ASHLEY BAZELAIS
Title or Position: OWNER
Credential: LMHC-D
Phone: 631-683-8072