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General NPI Number Information
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NPI Number | 1609556125
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Entity Type | Organization
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Legal Business Name | BLOOM COUNSELING CENTER, PLLC
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Dates
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Enumeration Date | 07/19/2023
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Last Update Date | 07/19/2023
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Provider Practice Location Address
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Address Line | 2408 PAWNEE AVE
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City | ALTUS
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State | OK
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Zip | 73521-1520
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Country | US
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Telephone | 580-301-4709
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 149
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City | ALTUS
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State | OK
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Zip | 73522-0149
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Country | US
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Telephone | 580-301-4709
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Fax | 888-885-3449
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Authorized Official
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Title or Position | COUNSELOR
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Name | MAURISA MAHAN
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Credential | LPC
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Telephone | 580-301-4709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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