Provider Demographics
NPI:1164203402
Name:BLOOM WELLNESS AND PSYCHIATRY PLLC
Entity Type:Organization
Organization Name:BLOOM WELLNESS AND PSYCHIATRY PLLC
Other - Org Name:AMANDA SISUL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SISUL
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:512-952-2644
Mailing Address - Street 1:13359 N HIGHWAY 183 STE 406-533
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-7153
Mailing Address - Country:US
Mailing Address - Phone:512-952-2644
Mailing Address - Fax:512-668-7885
Practice Address - Street 1:821 W 11TH ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2009
Practice Address - Country:US
Practice Address - Phone:512-952-2644
Practice Address - Fax:512-668-7885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty