Healthcare Provider Details

I. General information

NPI: 1497599179
Provider Name (Legal Business Name): BLOSSOMING BEGINNINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 POLENTA RD
CLAYTON NC
27520-8944
US

IV. Provider business mailing address

3021 POLENTA RD
CLAYTON NC
27520-8944
US

V. Phone/Fax

Practice location:
  • Phone: 919-390-4827
  • Fax:
Mailing address:
  • Phone: 919-390-4827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ASHLEY DOLIN MATTES
Title or Position: OWNER/ OCCUPATIONAL THERAPY
Credential: COTA/L
Phone: 919-390-4827