Healthcare Provider Details

I. General information

NPI: 1386558500
Provider Name (Legal Business Name): BLOOM ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 DELAWARE ST APT 1
LEAVENWORTH KS
66048-2772
US

IV. Provider business mailing address

22143 219TH ST
LEAVENWORTH KS
66048-8104
US

V. Phone/Fax

Practice location:
  • Phone: 913-547-1285
  • Fax:
Mailing address:
  • Phone: 913-705-0591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: COURTNEY TRIEB
Title or Position: OWNER
Credential: BCBA
Phone: 913-547-1285