Provider Demographics
NPI:1225896285
Name:BLOOM PSYCHOLOGY SP LLC
Entity Type:Organization
Organization Name:BLOOM PSYCHOLOGY SP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-775-3942
Mailing Address - Street 1:10100 LANTERN RD STE 125
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-7806
Mailing Address - Country:US
Mailing Address - Phone:317-775-3942
Mailing Address - Fax:317-775-3942
Practice Address - Street 1:10100 LANTERN RD STE 125
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7806
Practice Address - Country:US
Practice Address - Phone:317-775-3942
Practice Address - Fax:317-775-3942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty