Provider Demographics
NPI:1528442464
Name:BLOOM COUNSELING LLC
Entity type:Organization
Organization Name:BLOOM COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER COUNSELOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:E
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GARZA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:262-528-2015
Mailing Address - Street 1:510 HARTBROOK DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-1444
Mailing Address - Country:US
Mailing Address - Phone:262-528-2015
Mailing Address - Fax:866-284-8107
Practice Address - Street 1:510 HARTBROOK DR STE 201
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-1444
Practice Address - Country:US
Practice Address - Phone:262-528-2015
Practice Address - Fax:866-284-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5606-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100042870Medicaid
WI100045001Medicaid
WI100027690Medicaid