Provider Demographics
NPI:1053067124
Name:NOURISH2FLOURISH PSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:NOURISH2FLOURISH PSYCHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:812-929-4593
Mailing Address - Street 1:3849 S CRAMER CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-8997
Mailing Address - Country:US
Mailing Address - Phone:812-929-4593
Mailing Address - Fax:812-961-6551
Practice Address - Street 1:120 W 7TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404
Practice Address - Country:US
Practice Address - Phone:812-929-4593
Practice Address - Fax:812-961-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-26
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1588334171OtherPSYCHOLOGIST