Provider Demographics
NPI:1992152862
Name:SPIRIT IN BLOOM, LLC
Entity type:Organization
Organization Name:SPIRIT IN BLOOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-239-6262
Mailing Address - Street 1:5878 BLACKSHIRE PATH
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55076-1621
Mailing Address - Country:US
Mailing Address - Phone:612-239-6262
Mailing Address - Fax:651-774-9576
Practice Address - Street 1:5878 BLACKSHIRE PATH
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-1621
Practice Address - Country:US
Practice Address - Phone:612-239-6262
Practice Address - Fax:651-774-9576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14534261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNVN000088953001Medicaid