Healthcare Provider Details

I. General information

NPI: 1770853939
Provider Name (Legal Business Name): BLOOM BEHAVIOR THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 07/08/2021
Certification Date: 07/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 BENTON RD
PADUCAH KY
42003-1304
US

IV. Provider business mailing address

6201 BENTON RD
PADUCAH KY
42003-1304
US

V. Phone/Fax

Practice location:
  • Phone: 270-908-0461
  • Fax: 270-366-0780
Mailing address:
  • Phone: 270-908-0461
  • Fax: 270-366-0780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberKY-0016
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number800217
License Number StateKY

VIII. Authorized Official

Name: BECKY L NASTALLY
Title or Position: OWNER
Credential: PHD, BCBA-D, LBA
Phone: 270-908-0461