Provider Demographics
NPI:1336896786
Name:BLOOM BEHAVIORAL HEALTHCARE LLC
Entity Type:Organization
Organization Name:BLOOM BEHAVIORAL HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/BCBA
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:816-585-1272
Mailing Address - Street 1:14405 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-8400
Mailing Address - Country:US
Mailing Address - Phone:816-585-1272
Mailing Address - Fax:
Practice Address - Street 1:14405 SALEM RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-8400
Practice Address - Country:US
Practice Address - Phone:816-585-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty