=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255185658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND BLOOM COUNSELING P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2024
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 N CEDAR ST STE A
-----------------------------------------------------
City | LUVERNE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56156-1626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-608-5979
-----------------------------------------------------
Fax | 507-607-8774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 729 N CEDAR ST
-----------------------------------------------------
City | LUVERNE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56156-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-608-5979
-----------------------------------------------------
Fax | 507-607-8774
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JILL BOLTJES
-----------------------------------------------------
Credential | MA, LPCC
-----------------------------------------------------
Telephone | 507-608-5979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------