Healthcare Provider Details

I. General information

NPI: 1962340059
Provider Name (Legal Business Name): BLOOM AND BLOSSOM SPEECH THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 WINDWARD PT
CHAMPAIGN IL
61821-6962
US

IV. Provider business mailing address

1609 WINDWARD PT
CHAMPAIGN IL
61821-6962
US

V. Phone/Fax

Practice location:
  • Phone: 217-994-1615
  • Fax:
Mailing address:
  • Phone: 217-994-1615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY BOOTH
Title or Position: OWNER
Credential: SLP
Phone: 217-994-1615