Healthcare Provider Details

I. General information

NPI: 1083553424
Provider Name (Legal Business Name): BLOOM AUTISM CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 W CHARLESTON BLVD STE 130
LAS VEGAS NV
89146-1067
US

IV. Provider business mailing address

6600 W CHARLESTON BLVD STE 130
LAS VEGAS NV
89146-1067
US

V. Phone/Fax

Practice location:
  • Phone: 702-588-3425
  • Fax: 702-209-2090
Mailing address:
  • Phone: 702-588-3425
  • Fax: 702-209-2090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ROOSEVELT DAYMON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 702-588-3425