Provider Demographics
NPI:1841920477
Name:BLOOM THERAPY
Entity type:Organization
Organization Name:BLOOM THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKEDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-357-9183
Mailing Address - Street 1:4124 WATERMELON RD STE B
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5252
Mailing Address - Country:US
Mailing Address - Phone:334-357-9183
Mailing Address - Fax:
Practice Address - Street 1:6958 BRIGHTWELL LN
Practice Address - Street 2:
Practice Address - City:DORA
Practice Address - State:AL
Practice Address - Zip Code:35062-2613
Practice Address - Country:US
Practice Address - Phone:334-357-9183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty