Provider Demographics
NPI:1083972897
Name:BLOOM: CENTER FOR ART AND INTEGRATED THERAPIES, LLC
Entity Type:Organization
Organization Name:BLOOM: CENTER FOR ART AND INTEGRATED THERAPIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:C
Authorized Official - Last Name:NOLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC ATR-BC
Authorized Official - Phone:414-378-0602
Mailing Address - Street 1:2625 S GREELEY ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2027
Mailing Address - Country:US
Mailing Address - Phone:414-378-0602
Mailing Address - Fax:
Practice Address - Street 1:2625 S GREELEY ST
Practice Address - Street 2:SUITE 205
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-2027
Practice Address - Country:US
Practice Address - Phone:414-378-0602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4057-125251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health