Provider Demographics
NPI:1902339740
Name:BLOOM RECOVERY
Entity Type:Organization
Organization Name:BLOOM RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:F
Authorized Official - Last Name:RUNOLFSON
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:801-809-6011
Mailing Address - Street 1:2220 E MURRAY HOLLADAY RD
Mailing Address - Street 2:UNIT 186
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5377
Mailing Address - Country:US
Mailing Address - Phone:801-809-6011
Mailing Address - Fax:
Practice Address - Street 1:470 E 3900 S
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1880
Practice Address - Country:US
Practice Address - Phone:801-809-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-08
Last Update Date:2017-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8922867-6004101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty