Healthcare Provider Details

I. General information

NPI: 1205748852
Provider Name (Legal Business Name): THISTLE AND BLOOM COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WALNUT ST STE 901
PHILADELPHIA PA
19102-2905
US

IV. Provider business mailing address

390 COMMERCE DR
FORT WASHINGTON PA
19034-2600
US

V. Phone/Fax

Practice location:
  • Phone: 267-598-5603
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: GWENDOLYN GAUSE
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 267-598-5603