Healthcare Provider Details

I. General information

NPI: 1912572330
Provider Name (Legal Business Name): BLOSSOM BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2021
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4263 NEVADA ST
AVE MARIA FL
34142-5028
US

IV. Provider business mailing address

4263 NEVADA ST
AVE MARIA FL
34142-5028
US

V. Phone/Fax

Practice location:
  • Phone: 954-882-2142
  • Fax:
Mailing address:
  • Phone: 954-882-2142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TELMA SUARES
Title or Position: OWNER
Credential: BCBA
Phone: 954-882-2142