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General NPI Number Information
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NPI Number | 1205723335
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Entity Type | Organization
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Legal Business Name | BLOOM BEHAVIORAL NETWORK
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Dates
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Enumeration Date | 06/20/2025
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Last Update Date | 07/15/2025
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Provider Practice Location Address
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Address Line | 519 UNIVERSITY AVE W STE 100
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City | SAINT PAUL
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State | MN
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Zip | 55103-2162
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Country | US
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Telephone | 612-417-3206
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Fax |
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Provider Business Mailing Address
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Address Line | 8613 PLATINUM CV
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City | WOODBURY
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State | MN
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Zip | 55129-7559
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Country | US
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Telephone | 612-417-3206
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | HABONE MOUSSA
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Credential |
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Telephone | 612-424-2251
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number |
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License Number State |
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