MEDICARE: BLOOM THERAPY CLINIC LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1124972641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM THERAPY CLINIC LLC

Provider Business Mailing Address
First Line	:	5005 CAMINO DEL MAR VIA CANGREJOS
Second Line	:
City	:	TOA BAJA
State	:	PR
Zip	:	00949
Country	:	US
Telephone Number	:	787-949-5557
Fax Number	:

Provider Business Practice Location Address
First Line	:	1012 AVE DOS PALMAS
Second Line	:
City	:	TOA BAJA
State	:	PR
Zip	:	00949-4101
Country	:	US
Telephone Number	:	787-949-5557
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHAMARYS D RIVERA SANTANA
Credential	:	PSYD
Telephone Number	:	787-949-5557

Provider Enumeration Date	:	02/23/2026
Last Update Date	:	02/23/2026

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