Healthcare Provider Details

I. General information

NPI: 1780250035
Provider Name (Legal Business Name): BLOOMING MINDS PSYCHOTHERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N 5TH ST STE 9
SHEBOYGAN WI
53081-4623
US

IV. Provider business mailing address

1432 N 10TH ST
SHEBOYGAN WI
53081-3332
US

V. Phone/Fax

Practice location:
  • Phone: 920-977-3111
  • Fax: 920-482-5662
Mailing address:
  • Phone: 920-912-8628
  • Fax: 920-482-5662

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MINDY KUE
Title or Position: OWNER
Credential: LPC
Phone: 920-977-3111