Healthcare Provider Details

I. General information

NPI: 1073464897
Provider Name (Legal Business Name): AUTISM BLOOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 MAIN ST STE 3C
MARTINEZ CA
94553-1102
US

IV. Provider business mailing address

3223 MUNRAS PL
SAN RAMON CA
94583-3039
US

V. Phone/Fax

Practice location:
  • Phone: 925-905-9077
  • Fax:
Mailing address:
  • Phone: 925-905-9077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA KURNIAWAN
Title or Position: MANAGING MEMBER
Credential: BCBA
Phone: 818-433-0492