Healthcare Provider Details

I. General information

NPI: 1477362192
Provider Name (Legal Business Name): BLOOM & THRIVE WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 CONANT ST SUITE 201
MAUMEE OH
43537-4214
US

IV. Provider business mailing address

1331 CONANT ST SUITE 201
MAUMEE OH
43537-4214
US

V. Phone/Fax

Practice location:
  • Phone: 419-665-1277
  • Fax:
Mailing address:
  • Phone: 419-665-1277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: NICOLE BOLDUC
Title or Position: CEO
Credential: MSW, LISW-S, LICDC
Phone: 419-665-1277