Provider Demographics
NPI:1619662244
Name:PROSPER & BLOOM MENTAL HEALTH, LLC
Entity type:Organization
Organization Name:PROSPER & BLOOM MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:225-605-3103
Mailing Address - Street 1:1765 ONEAL LN # 479
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-1633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN ST STE 2200
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70801-0014
Practice Address - Country:US
Practice Address - Phone:225-605-3103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty