Provider Demographics
NPI:1093523904
Name:BLOOM WELLNESS LLC
Entity type:Organization
Organization Name:BLOOM WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, SUPERVISOR, CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGNUSON
Authorized Official - Suffix:
Authorized Official - Credentials:LSCW
Authorized Official - Phone:303-408-8056
Mailing Address - Street 1:417 BEAVER POND RD
Mailing Address - Street 2:
Mailing Address - City:DIVIDE
Mailing Address - State:CO
Mailing Address - Zip Code:80814-7792
Mailing Address - Country:US
Mailing Address - Phone:719-286-9077
Mailing Address - Fax:
Practice Address - Street 1:100 W BENNETT AVENUE
Practice Address - Street 2:
Practice Address - City:CRIPPLE CREEK
Practice Address - State:CO
Practice Address - Zip Code:80813
Practice Address - Country:US
Practice Address - Phone:719-286-9077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLOOM WELLNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty