MEDICARE: BLOOMWELL BEHAVIORAL HEALTH INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	235Z00000X	Speech-Language Pathologist
2	103T00000X	Psychologist
3	106E00000X	Assistant Behavior Analyst
4	106S00000X	Behavior Technician
5	225100000X	Physical Therapist
6	225X00000X	Occupational Therapist
7	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1396533600
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMWELL BEHAVIORAL HEALTH INC.

Provider Business Mailing Address
First Line	:	382 NE 191ST ST STE 98090
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33179-3899
Country	:	US
Telephone Number	:	612-201-2468
Fax Number	:	919-561-6112

Provider Business Practice Location Address
First Line	:	2829 N 90TH ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68134-5774
Country	:	US
Telephone Number	:	401-819-4059
Fax Number	:	919-561-6112

Authorized Official
Title or Position	:	CEO
Name	:	LOGAN PRATT
Credential	:
Telephone Number	:	612-201-2468

Provider Enumeration Date	:	04/28/2025
Last Update Date	:	04/28/2025

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