Healthcare Provider Details

I. General information

NPI: 1295329654
Provider Name (Legal Business Name): BLOOM BEHAVIOR SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 W 14TH ST STE 230
WASHINGTON MO
63090-7003
US

IV. Provider business mailing address

901 W 14TH ST STE 230
WASHINGTON MO
63090-4198
US

V. Phone/Fax

Practice location:
  • Phone: 573-480-0440
  • Fax:
Mailing address:
  • Phone: 636-432-6709
  • Fax: 636-432-1559

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: MS. SALLY MARIE LAVIGNE
Title or Position: OWNER/BCBA
Credential: BCBA
Phone: 573-480-0440