Provider Demographics
NPI:1427693613
Name:BLOOM MENTAL HEALTH LLC
Entity type:Organization
Organization Name:BLOOM MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:GALLE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:228-343-0325
Mailing Address - Street 1:PO BOX 8592
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8592
Mailing Address - Country:US
Mailing Address - Phone:225-343-0325
Mailing Address - Fax:
Practice Address - Street 1:933 TOMMY MUNRO DR.
Practice Address - Street 2:SUITE C
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532
Practice Address - Country:US
Practice Address - Phone:228-343-0325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-12
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR864186OtherSTATE LICENSE