MEDICARE: BLOOM AND GROW THERAPY CENTER

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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1871270454
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM AND GROW THERAPY CENTER

Provider Business Mailing Address
First Line	:	36599 LODGE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-3319
Country	:	US
Telephone Number	:	586-855-2414
Fax Number	:

Provider Business Practice Location Address
First Line	:	36599 LODGE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-3319
Country	:	US
Telephone Number	:	586-855-2414
Fax Number	:

Authorized Official
Title or Position	:	OWNER/SPEECH-LANGUAGE PATHOLOGIST
Name	:	MALERIE A DAVIS
Credential	:
Telephone Number	:	586-855-2414

Provider Enumeration Date	:	07/05/2023
Last Update Date	:	07/05/2023

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