MEDICARE: IN BLOOM BEHAVIORAL HEALTH CARE

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	103TC0700X	Clinical Psychologist	0015000751	VA

General Provider Information

NPI Number	:	1104053008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IN BLOOM BEHAVIORAL HEALTH CARE

Provider Business Mailing Address
First Line	:	15 TERRY CT
Second Line	:	SUITE D
City	:	STAUNTON
State	:	VA
Zip	:	24401-2568
Country	:	US
Telephone Number	:	540-887-2847
Fax Number	:	540-887-2848

Provider Business Practice Location Address
First Line	:	15 TERRY CT
Second Line	:	SUITE D
City	:	STAUNTON
State	:	VA
Zip	:	24401-2568
Country	:	US
Telephone Number	:	540-887-2847
Fax Number	:	540-887-2848

Authorized Official
Title or Position	:	OWNER
Name	:	CINDY H PACKER
Credential	:
Telephone Number	:	540-887-2847

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	06/18/2009

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