Provider Demographics
NPI:1215547831
Name:IN BLOOM MENTAL HEALTH COUNSELING, LLC
Entity Type:Organization
Organization Name:IN BLOOM MENTAL HEALTH COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANDELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HETHER-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LCPC
Authorized Official - Phone:347-509-7127
Mailing Address - Street 1:2324 W JOPPA RD STE 410
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4620
Mailing Address - Country:US
Mailing Address - Phone:443-446-4718
Mailing Address - Fax:347-391-0191
Practice Address - Street 1:247 PROSPECT AVE STE 4H
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-8403
Practice Address - Country:US
Practice Address - Phone:347-509-7127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty