Provider Demographics
NPI:1609253277
Name:BLOOMING MINDS, INC
Entity Type:Organization
Organization Name:BLOOMING MINDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CRISTINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:STILES
Authorized Official - Suffix:
Authorized Official - Credentials:SLP, MS, CCC-SLP
Authorized Official - Phone:208-713-3463
Mailing Address - Street 1:1034 N 3RD ST
Mailing Address - Street 2:SUITE 5B
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3145
Mailing Address - Country:US
Mailing Address - Phone:208-713-3463
Mailing Address - Fax:
Practice Address - Street 1:1034 N 3RD ST
Practice Address - Street 2:SUITE 5B
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3145
Practice Address - Country:US
Practice Address - Phone:208-713-3463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-02
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-2231235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770954794OtherINDIVIDUAL NPI
1154671048OtherINDIVIDUAL NPI