Healthcare Provider Details

I. General information

NPI: 1548639883
Provider Name (Legal Business Name): BLOOMING TREE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CHERRY ST
BROOKLAND AR
72417-8839
US

IV. Provider business mailing address

115 CHERRY ST
BROOKLAND AR
72417-8839
US

V. Phone/Fax

Practice location:
  • Phone: 870-336-2778
  • Fax: 870-336-9055
Mailing address:
  • Phone: 870-336-2778
  • Fax: 870-336-9055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: LONA M MILES
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 870-819-1666