Healthcare Provider Details

I. General information

NPI: 1700105566
Provider Name (Legal Business Name): AS CHILDREN BLOSSOM THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 E CAMPBELL AVE SUITE 11A
CAMPBELL CA
95008-2139
US

IV. Provider business mailing address

621 E CAMPBELL AVE SUITE 11A
CAMPBELL CA
95008-2139
US

V. Phone/Fax

Practice location:
  • Phone: 408-866-4700
  • Fax: 408-866-1700
Mailing address:
  • Phone: 408-866-4700
  • Fax: 408-866-1700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. JODI E HUBER
Title or Position: OWNER/PARTNER
Credential: M.A. OTR/L
Phone: 408-866-4700