Provider Demographics
NPI:1831853480
Name:BLOOM365
Entity type:Organization
Organization Name:BLOOM365
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:UHLEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:602-820-3925
Mailing Address - Street 1:20403 N LAKE PLEASANT RD # 117-492
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9702
Mailing Address - Country:US
Mailing Address - Phone:888-606-4673
Mailing Address - Fax:
Practice Address - Street 1:1715 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-5472
Practice Address - Country:US
Practice Address - Phone:888-606-4673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty