Healthcare Provider Details

I. General information

NPI: 1174153449
Provider Name (Legal Business Name): BLOSSOM BEHAVIOR CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2020
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13706 SW 56TH ST STE 105-106
MIAMI FL
33175-6036
US

IV. Provider business mailing address

13706 SW 56TH ST STE 105-106
MIAMI FL
33175-6036
US

V. Phone/Fax

Practice location:
  • Phone: 786-688-2630
  • Fax: 786-513-8495
Mailing address:
  • Phone: 786-688-2630
  • Fax: 786-513-8495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LISDEYBYS BATLLE LORENTE
Title or Position: PRESIDENT
Credential:
Phone: 786-523-4289