Provider Demographics
NPI:1669030516
Name:BLOOMINGLIFE LLC
Entity Type:Organization
Organization Name:BLOOMINGLIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:616-275-2288
Mailing Address - Street 1:1121 BRETON RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3529
Mailing Address - Country:US
Mailing Address - Phone:616-275-2288
Mailing Address - Fax:
Practice Address - Street 1:221 TROWBRIDGE ST NE APT 208
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1891
Practice Address - Country:US
Practice Address - Phone:616-499-7711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401003114OtherSTATE OF MICHIGAN LICENSE