Provider Demographics
NPI:1760090724
Name:BLOOM THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:BLOOM THERAPY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DORN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LISW-CP
Authorized Official - Phone:920-460-6834
Mailing Address - Street 1:120 GANTT ST STE 8
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-2811
Mailing Address - Country:US
Mailing Address - Phone:803-470-4026
Mailing Address - Fax:
Practice Address - Street 1:120 GANTT ST STE 8
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2811
Practice Address - Country:US
Practice Address - Phone:803-470-4026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty