Healthcare Provider Details

I. General information

NPI: 1821929431
Provider Name (Legal Business Name): BLOOMING WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N8030 TOWNLINE RD
EAST TROY WI
53120-3500
US

IV. Provider business mailing address

12581 DUNCAN LN UNIT 103
NEW BERLIN WI
53151-8796
US

V. Phone/Fax

Practice location:
  • Phone: 262-228-8931
  • Fax:
Mailing address:
  • Phone: 262-228-8931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JADE ELIZABETH FOWLER
Title or Position: PRESIDENT
Credential: MS, LPC, NCC
Phone: 608-772-9895