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General NPI Number Information
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NPI Number | 1083098495
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Entity Type | Organization
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Legal Business Name | BLOOM PSYCHOLOGICAL SERVICES, LLC
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Dates
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Enumeration Date | 07/15/2015
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Last Update Date | 07/15/2015
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Provider Practice Location Address
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Address Line | 1520 29TH AVE SUITE 31
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City | GULFPORT
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State | MS
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Zip | 39501-2843
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Country | US
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Telephone | 228-547-2273
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1583
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City | LONG BEACH
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State | MS
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Zip | 39560-1583
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Country | US
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Telephone | 228-547-2273
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Fax | 877-895-6469
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Authorized Official
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Title or Position | OWNER
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Name | DR. HOLLY MICHELLE SPOTTS
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Credential | PSY.D.
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Telephone | 228-547-2273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 54965
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License Number State | MS
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