MEDICARE: NURTURE AND BLOOM THERAPY 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	:	1558040030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NURTURE AND BLOOM THERAPY LLC

Provider Business Mailing Address
First Line	:	629 W MAIN ST # 1035
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-2221
Country	:	US
Telephone Number	:	405-901-1793
Fax Number	:	405-351-4247

Provider Business Practice Location Address
First Line	:	629 W MAIN ST # 1035
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-2221
Country	:	US
Telephone Number	:	405-901-1793
Fax Number	:	405-351-4247

Authorized Official
Title or Position	:	OWNER
Name	:	KAREN DURHAM
Credential	:	LCSW
Telephone Number	:	405-901-1793

Provider Enumeration Date	:	07/13/2023
Last Update Date	:	10/21/2023

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