Healthcare Provider Details

I. General information

NPI: 1649108226
Provider Name (Legal Business Name): INNERBLOOM THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 S LEGEND HILLS DR STE 327
CLEARFIELD UT
84015-1592
US

IV. Provider business mailing address

819 S 2200 W
SYRACUSE UT
84075-7187
US

V. Phone/Fax

Practice location:
  • Phone: 385-558-8466
  • Fax:
Mailing address:
  • Phone: 385-558-8466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CONNIE POWELL
Title or Position: LCSW
Credential:
Phone: 385-558-8466