Healthcare Provider Details

I. General information

NPI: 1801716592
Provider Name (Legal Business Name): BLOOM THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 NE STUCKI AVE STE 400
HILLSBORO OR
97006-6938
US

IV. Provider business mailing address

1915 NE STUCKI AVE STE 400
HILLSBORO OR
97006-6938
US

V. Phone/Fax

Practice location:
  • Phone: 971-545-4936
  • Fax: 971-250-0133
Mailing address:
  • Phone: 971-545-4936
  • Fax: 971-250-0133

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: NAIYANA CHANTARABUNCHORN
Title or Position: PSYCHOTHERAPIST/OWNER
Credential: PHD, NCC, LPC
Phone: 971-545-4936