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General NPI Number Information
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NPI Number | 1013820992
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Entity Type | Organization
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Legal Business Name | PHOENIX BLOOM FAMILY FOUNDATION, INC.
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Dates
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Enumeration Date | 09/23/2026
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Last Update Date | 09/23/2026
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Provider Practice Location Address
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Address Line | 31 HIDEAWAY DR
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City | COVINGTON
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State | KY
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Zip | 41017-9775
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Country | US
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Telephone | 859-307-4540
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Fax |
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Provider Business Mailing Address
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Address Line | 31 HIDEAWAY DR
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City | COVINGTON
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State | KY
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Zip | 41017-9775
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Country | US
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Telephone | 859-307-4540
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | TINA NICHOLE HACKER
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Credential | LMFT, IMFT, LICDC
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Telephone | 859-307-4540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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