Provider Demographics
NPI:1790523173
Name:SUPERBLOOM PSYCHIATRY LLC
Entity type:Organization
Organization Name:SUPERBLOOM PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:912-596-7573
Mailing Address - Street 1:7 SAXONY CT
Mailing Address - Street 2:
Mailing Address - City:PIKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3319
Mailing Address - Country:US
Mailing Address - Phone:912-596-7573
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN ST STE 2D
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1957
Practice Address - Country:US
Practice Address - Phone:443-203-8613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health