Healthcare Provider Details

I. General information

NPI: 1497399026
Provider Name (Legal Business Name): REBEL IN BLOOM, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 SOUTH LAMAR BLVD, STE 15
AUSTIN TX
78704-4789
US

IV. Provider business mailing address

2525 SOUTH LAMAR BLVD, STE 15
AUSTIN TX
78704-4789
US

V. Phone/Fax

Practice location:
  • Phone: 512-920-5317
  • Fax: 512-920-5317
Mailing address:
  • Phone: 512-920-5317
  • Fax: 512-920-5317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NATALIA LUX AMARI
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LCSW
Phone: 512-920-5317