Healthcare Provider Details

I. General information

NPI: 1770287823
Provider Name (Legal Business Name): BLUE BLOSSOM CARE ABA THERAPY LLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 SILVERGATE WAY
WINDER GA
30680-6101
US

IV. Provider business mailing address

1431 SILVERGATE WAY
WINDER GA
30680-6101
US

V. Phone/Fax

Practice location:
  • Phone: 470-561-0340
  • Fax:
Mailing address:
  • Phone: 470-561-0340
  • 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 Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. MANUEL ALEJANDRO PEREZ
Title or Position: CEO/OWNER
Credential:
Phone: 470-561-0340