=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164105821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOOMING MAGNOLIAS THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2023
-----------------------------------------------------
Last Update Date | 12/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 842 W SOUTH BOUNDARY ST
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-5265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-406-4780
-----------------------------------------------------
Fax | 419-458-5081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 842 W SOUTH BOUNDARY ST
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-5265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-406-4780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SABRINA HOWARD
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 419-406-4780
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------