Provider Demographics
NPI:1295327682
Name:FULL BLOOM THERAPY SERVICES LLC
Entity type:Organization
Organization Name:FULL BLOOM THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LCADC
Authorized Official - Phone:732-640-8593
Mailing Address - Street 1:2600 TILTON RD # 1014
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-1831
Mailing Address - Country:US
Mailing Address - Phone:732-640-8593
Mailing Address - Fax:
Practice Address - Street 1:2600 TILTON RD # 1014
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-1831
Practice Address - Country:US
Practice Address - Phone:732-640-8593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-07
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health