Provider Demographics
NPI:1053695593
Name:BLOOMING PATH, LLC
Entity type:Organization
Organization Name:BLOOMING PATH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:S
Authorized Official - Last Name:VERGARA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:512-481-2452
Mailing Address - Street 1:306 E MAIN ST
Mailing Address - Street 2:STE# 102
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-5215
Mailing Address - Country:US
Mailing Address - Phone:512-481-2452
Mailing Address - Fax:512-535-5880
Practice Address - Street 1:306 E MAIN ST
Practice Address - Street 2:STE# 102
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-5215
Practice Address - Country:US
Practice Address - Phone:512-481-2452
Practice Address - Fax:512-535-5880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65961101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty