MEDICARE: BLOOMING PATHWAYS 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	:	1831910637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMING PATHWAYS THERAPY LLC

Provider Business Mailing Address
First Line	:	W292S2954 ANCESTRAL DR
Second Line	:
City	:	WAUKESHA
State	:	WI
Zip	:	53188-9203
Country	:	US
Telephone Number	:	262-955-7786
Fax Number	:

Provider Business Practice Location Address
First Line	:	245 REGENCY CT STE 200
Second Line	:
City	:	BROOKFIELD
State	:	WI
Zip	:	53045-6167
Country	:	US
Telephone Number	:	262-955-7786
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOTHERAPIST, OWNER
Name	:	MELISSA LEE MANGANELLO
Credential	:	LCSW
Telephone Number	:	262-955-7786

Provider Enumeration Date	:	10/23/2024
Last Update Date	:	10/23/2024

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