Provider Demographics
NPI:1780335737
Name:BLOOM PSYCHOTHERAPY AND EMPOWERMENT SERVICES
Entity type:Organization
Organization Name:BLOOM PSYCHOTHERAPY AND EMPOWERMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:NCC LPC
Authorized Official - Phone:318-446-0592
Mailing Address - Street 1:4501 JACKSON ST EXT STE C
Mailing Address - Street 2:BOX #285
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2555
Mailing Address - Country:US
Mailing Address - Phone:318-723-7237
Mailing Address - Fax:
Practice Address - Street 1:5420 DOWNING ST APT 8C
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3120
Practice Address - Country:US
Practice Address - Phone:318-723-7237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty