MEDICARE: BLOOM BEHAVIORAL HEALTH & WELLNESS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1083314629
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM BEHAVIORAL HEALTH & WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	2416 FALLINGWATER LN APT 102
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38016-7686
Country	:	US
Telephone Number	:	901-870-8624
Fax Number	:	662-265-9483

Provider Business Practice Location Address
First Line	:	200 S RHODES ST STE E
Second Line	:
City	:	WEST MEMPHIS
State	:	AR
Zip	:	72301-4213
Country	:	US
Telephone Number	:	662-912-6024
Fax Number	:	662-265-9483

Authorized Official
Title or Position	:	OWNER, PROVIDER
Name	:	CHARLEDRIA MCGEE
Credential	:	DNP, PMHNP
Telephone Number	:	901-870-8624

Provider Enumeration Date	:	03/02/2023
Last Update Date	:	03/02/2023

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