Provider Demographics
NPI:1114593399
Name:BLOOM BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:BLOOM BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:904-788-9474
Mailing Address - Street 1:32 OLIVINE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-0350
Mailing Address - Country:US
Mailing Address - Phone:904-788-9474
Mailing Address - Fax:760-205-4866
Practice Address - Street 1:2473 KARL DR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6511
Practice Address - Country:US
Practice Address - Phone:904-788-9474
Practice Address - Fax:760-205-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-28
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164790143OtherNPI
CA1164790143OtherNPI 1