Provider Demographics
NPI:1003312943
Name:BLOOM BEHAVIORAL THERAPY LLC
Entity Type:Organization
Organization Name:BLOOM BEHAVIORAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MADELINE
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:REHM
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:864-383-0384
Mailing Address - Street 1:25B RUSHMORE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-1254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25B RUSHMORE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-1254
Practice Address - Country:US
Practice Address - Phone:864-383-0384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-31
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11284101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1450Medicaid