Healthcare Provider Details

I. General information

NPI: 1104756139
Provider Name (Legal Business Name): KARLI BLOSSOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17110 MARCY ST STE 110
OMAHA NE
68118-3123
US

IV. Provider business mailing address

17110 MARCY ST STE 110
OMAHA NE
68118-3123
US

V. Phone/Fax

Practice location:
  • Phone: 402-792-4524
  • Fax:
Mailing address:
  • Phone: 402-792-4524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14929
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: