MEDICARE: CASA BLOOM 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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1942150651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASA BLOOM LLC

Provider Business Mailing Address
First Line	:	5219 KODIAK CT
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-8735
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2706 MAIN AVE NW
Second Line	:
City	:	HICKORY
State	:	NC
Zip	:	28601-5635
Country	:	US
Telephone Number	:	404-630-0592
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR/THERAPIST
Name	:	STA'NESHA RIVERO
Credential	:	MSW,LCSW
Telephone Number	:	404-630-0592

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

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