Provider Demographics
NPI:1598484966
Name:BLOOM PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:BLOOM PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:774-244-0598
Mailing Address - Street 1:3 HOLLY LN
Mailing Address - Street 2:
Mailing Address - City:WEST TISBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02575-5316
Mailing Address - Country:US
Mailing Address - Phone:774-244-0598
Mailing Address - Fax:
Practice Address - Street 1:3 HOLLY LN
Practice Address - Street 2:
Practice Address - City:WEST TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02575-5316
Practice Address - Country:US
Practice Address - Phone:774-244-0598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty