=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417812587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOOMING INTEGRATIVE PSYCHIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2025
-----------------------------------------------------
Last Update Date | 12/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23283 CANYON LAKE DR S
-----------------------------------------------------
City | CANYON LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92587-7598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-387-0782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31566 RAILROAD CANYON RD STE 2
-----------------------------------------------------
City | CANYON LAKE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92587-9446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-387-0782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | HANNAH FRALEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-387-0782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------