Healthcare Provider Details

I. General information

NPI: 1356250302
Provider Name (Legal Business Name): RADIANT BLOOM THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 W BELTLINE HWY STE 204
MADISON WI
53713-2832
US

IV. Provider business mailing address

827 BLUE CRANE RUN
VERONA WI
53593-9187
US

V. Phone/Fax

Practice location:
  • Phone: 347-395-6182
  • Fax:
Mailing address:
  • Phone: 347-395-6182
  • Fax:

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: ANASTASIA S HOLLAND
Title or Position: LPC, LMHC
Credential: LPC, LMHC
Phone: 347-395-6182