Provider Demographics
NPI:1922988849
Name:MIND BLOOM LLC
Entity type:Organization
Organization Name:MIND BLOOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLOA
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:864-274-3053
Mailing Address - Street 1:818 E MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-2000
Mailing Address - Country:US
Mailing Address - Phone:864-274-3053
Mailing Address - Fax:
Practice Address - Street 1:818 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-2000
Practice Address - Country:US
Practice Address - Phone:864-274-3053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty