Provider Demographics
NPI:1629570056
Name:BLOOM THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:BLOOM THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:240-758-2142
Mailing Address - Street 1:7303 HANOVER PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2029
Mailing Address - Country:US
Mailing Address - Phone:240-758-2142
Mailing Address - Fax:240-668-3690
Practice Address - Street 1:7303 HANOVER PKWY STE C
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2029
Practice Address - Country:US
Practice Address - Phone:240-758-2142
Practice Address - Fax:301-441-2511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6689101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty