Provider Demographics
NPI:1104617133
Name:NEURO BLOOM THERAPY
Entity type:Organization
Organization Name:NEURO BLOOM THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EFRAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-932-9111
Mailing Address - Street 1:600 TWELVE OAKS CENTER DR STE 218
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4548
Mailing Address - Country:US
Mailing Address - Phone:404-932-9111
Mailing Address - Fax:
Practice Address - Street 1:600 TWELVE OAKS CENTER DR STE 218
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4548
Practice Address - Country:US
Practice Address - Phone:404-932-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health