Provider Demographics
NPI:1780250035
Name:BLOOMING MINDS PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:BLOOMING MINDS PSYCHOTHERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KUE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:920-977-3111
Mailing Address - Street 1:1432 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3332
Mailing Address - Country:US
Mailing Address - Phone:920-912-8628
Mailing Address - Fax:920-482-5662
Practice Address - Street 1:601 N 5TH ST STE 9
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-4623
Practice Address - Country:US
Practice Address - Phone:920-977-3111
Practice Address - Fax:920-482-5662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-27
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780250035Medicaid