MEDICARE: BLOSSOM : DEVELOPMENTAL THERAPY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	PT17800	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184908139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOSSOM : DEVELOPMENTAL THERAPY ASSOCIATES

Provider Business Mailing Address
First Line	:	3111 PONCE DE LEON
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3111 PONCE DE LEON
Second Line	:
City	:	CORAL GABLES
State	:	FL
Zip	:	33134
Country	:	US
Telephone Number	:	305-444-9807
Fax Number	:	305-444-9808

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JENNIFER A BURCH
Credential	:	MPT
Telephone Number	:	305-444-9807

Provider Enumeration Date	:	10/07/2011
Last Update Date	:	10/07/2011

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