Provider Demographics
NPI:1104788181
Name:INTRABLOOM
Entity type:Organization
Organization Name:INTRABLOOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:
Authorized Official - Last Name:POE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-721-9950
Mailing Address - Street 1:971 US HIGHWAY 202 N STE R
Mailing Address - Street 2:
Mailing Address - City:BRANCHBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-3757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 ESSEX AVE
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1210
Practice Address - Country:US
Practice Address - Phone:609-721-9950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-28
Last Update Date:2025-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health