Healthcare Provider Details

I. General information

NPI: 1265312201
Provider Name (Legal Business Name): SPROUT AND BLOOM THERAPY SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 FAST PARK DR STE 301
RALEIGH NC
27617-4853
US

IV. Provider business mailing address

8801 FAST PARK DR STE 301
RALEIGH NC
27617-4853
US

V. Phone/Fax

Practice location:
  • Phone: 213-400-4447
  • Fax: 213-631-4140
Mailing address:
  • Phone: 213-400-4447
  • Fax: 213-631-4140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: SHANEE FULTON
Title or Position: OWNER
Credential: M.S. CCC/SLP, M.S.
Phone: 213-400-4447