Provider Demographics
NPI:1295315026
Name:BLOOM CHILD AND FAMILY THERAPY
Entity type:Organization
Organization Name:BLOOM CHILD AND FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-373-0529
Mailing Address - Street 1:419 N 1ST ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3703
Mailing Address - Country:US
Mailing Address - Phone:970-765-7162
Mailing Address - Fax:
Practice Address - Street 1:419 N 1ST ST UNIT D
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3703
Practice Address - Country:US
Practice Address - Phone:970-765-7162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24830071Medicaid