MEDICARE: BLOOM MINDFULLY COUNSELING 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1376349043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM MINDFULLY COUNSELING PLLC

Provider Business Mailing Address
First Line	:	86 BUFF CAP RD APT E4
Second Line	:
City	:	TOLLAND
State	:	CT
Zip	:	06084-2643
Country	:	US
Telephone Number	:	860-248-6284
Fax Number	:

Provider Business Practice Location Address
First Line	:	1212 BOSTON TPKE STE B
Second Line	:
City	:	BOLTON
State	:	CT
Zip	:	06043-7451
Country	:	US
Telephone Number	:	860-246-6284
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CLINICIAN
Name	:	MACKENZIE PHELPS
Credential	:	LCSW
Telephone Number	:	860-246-6284

Provider Enumeration Date	:	02/21/2025
Last Update Date	:	04/01/2025

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