Provider Demographics
NPI:1114649019
Name:BLOOMING MINDS, PLLC
Entity Type:Organization
Organization Name:BLOOMING MINDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:V
Authorized Official - Last Name:BLANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-673-1444
Mailing Address - Street 1:4700 RIVERWOOD CIR APT 368
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5761
Mailing Address - Country:US
Mailing Address - Phone:313-673-1444
Mailing Address - Fax:
Practice Address - Street 1:4700 RIVERWOOD CIR APT 368
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5761
Practice Address - Country:US
Practice Address - Phone:313-673-1444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health