Provider Demographics
NPI:1871372326
Name:IN FULL BLOOM COUNSELING
Entity type:Organization
Organization Name:IN FULL BLOOM COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA LPCC
Authorized Official - Phone:573-271-0785
Mailing Address - Street 1:2780 NEW HOLT ROAD
Mailing Address - Street 2:STE D PMB #326
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001
Mailing Address - Country:US
Mailing Address - Phone:573-271-0785
Mailing Address - Fax:
Practice Address - Street 1:108 CAMELLIA DR
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-271-0785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty