Healthcare Provider Details

I. General information

NPI: 1467268490
Provider Name (Legal Business Name): BLOOM THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 WALNUT ST
DERIDDER LA
70634-2731
US

IV. Provider business mailing address

1103 WALNUT ST
DERIDDER LA
70634-2731
US

V. Phone/Fax

Practice location:
  • Phone: 337-202-0568
  • Fax:
Mailing address:
  • Phone: 337-202-0568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: SARAH BRACK
Title or Position: MANAGER, OTR
Credential: MOT
Phone: 337-202-0568