Healthcare Provider Details

I. General information

NPI: 1164342879
Provider Name (Legal Business Name): BLOOM THERAPEUTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1782 E MOMBO DR
SANDY UT
84092-3016
US

IV. Provider business mailing address

1782 E MOMBO DR
SANDY UT
84092-3016
US

V. Phone/Fax

Practice location:
  • Phone: 801-455-4667
  • Fax:
Mailing address:
  • Phone: 801-455-4667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARAN BLOOMINGDALE
Title or Position: OWNER
Credential: CMHC, ATR-P
Phone: 801-455-4667