Healthcare Provider Details

I. General information

NPI: 1306503644
Provider Name (Legal Business Name): PATHWAYS IN BLOOM PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 COMMERCE DRIVE SUITE 104
LAKELAND FL
33813
US

IV. Provider business mailing address

13194 US HIGHWAY 301 S # 272
RIVERVIEW FL
33578-7410
US

V. Phone/Fax

Practice location:
  • Phone: 702-326-6959
  • Fax:
Mailing address:
  • Phone: 702-326-6959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIELLA MARIE VASQUEZ
Title or Position: OWNER/LICENSED CLINICAL PSYCHOLOGIS
Credential: PSY.D.
Phone: 813-436-3588