Organization
BLOOM BEHAVIORAL HEALTH LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ELENA GONZALEZ LMFT (OWNER)
(904) 788-9474
Entity
Organization
Contact information
Practice address
2473 KARL DR, PORT ORANGE, FL 32128-6511
(904) 788-9474
(760) 205-4866
Mailing address
32 OLIVINE CT, SAINT AUGUSTINE, FL 32086-0350
(904) 788-9474
(760) 205-4866
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1164790143
NPI 1
CA
01
—
1164790143
NPI
—
Enumeration date
05/28/2021
Last updated
05/11/2023
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