1780250035 NPI number — BLOOMING MINDS PSYCHOTHERAPY LLC

Table of content: (NPI 1780250035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780250035 NPI number — BLOOMING MINDS PSYCHOTHERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOOMING MINDS PSYCHOTHERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MINDY KUE LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780250035
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1432 N 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHEBOYGAN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53081-3332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-912-8628
Provider Business Mailing Address Fax Number:
920-482-5662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 N 5TH ST STE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEBOYGAN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53081-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-977-3111
Provider Business Practice Location Address Fax Number:
920-482-5662
Provider Enumeration Date:
05/27/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KUE
Authorized Official First Name:
MINDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
920-977-3111

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1780250035 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".