Healthcare Provider Details

I. General information

NPI: 1508705229
Provider Name (Legal Business Name): BLOOM MENTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 N 490 W
AMERICAN FORK UT
84003-2264
US

IV. Provider business mailing address

57 N 490 W
AMERICAN FORK UT
84003-2264
US

V. Phone/Fax

Practice location:
  • Phone: 801-421-3925
  • Fax:
Mailing address:
  • Phone: 801-421-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CARISSA ROBINSON
Title or Position: OWNER/PROVIDER
Credential: PMHNP
Phone: 801-358-8661