=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033844741
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOOM COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2022
-----------------------------------------------------
Last Update Date | 07/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 426 SCRABBLETOWN RD
-----------------------------------------------------
City | NORTH KINGSTOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02852-3664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-203-7407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 MIDWAY DR
-----------------------------------------------------
City | NORTH KINGSTOWN
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02852-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-741-3870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MEAGAN PETERSON
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 401-741-3870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------