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General NPI Number Information
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NPI Number | 1720794852
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Entity Type | Organization
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Legal Business Name | BLOOM THERAPY LLC
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Dates
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Enumeration Date | 01/23/2023
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Last Update Date | 02/03/2023
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Provider Practice Location Address
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Address Line | 112 SHOSHONE ST. E.SUITE 210
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City | TWIN FALLS
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State | ID
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Zip | 83301-8330
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Country | US
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Telephone | 208-420-5336
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Fax |
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Provider Business Mailing Address
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Address Line | 847 SUN PEAK WAY
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City | TWIN FALLS
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State | ID
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Zip | 83301-8977
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Country | US
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Telephone | 208-420-5336
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | IRMA PAVLOVIC
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Credential | LCSW
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Telephone | 208-420-5336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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