Provider Demographics
NPI:1871355529
Name:BLOOM THERAPY LLC
Entity type:Organization
Organization Name:BLOOM THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABIGAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:307-214-0229
Mailing Address - Street 1:1616 E 19TH ST STE 3
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4946
Mailing Address - Country:US
Mailing Address - Phone:307-214-0229
Mailing Address - Fax:
Practice Address - Street 1:1616 E 19TH ST STE 3
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4946
Practice Address - Country:US
Practice Address - Phone:307-214-0229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)