Healthcare Provider Details

I. General information

NPI: 1275453292
Provider Name (Legal Business Name): BLOOM PEDIATRIC SPEECH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 NW 150TH ST
OKLAHOMA CITY OK
73134-2004
US

IV. Provider business mailing address

14820 MARBLELEAF DR
EDMOND OK
73013-1468
US

V. Phone/Fax

Practice location:
  • Phone: 918-527-5360
  • Fax:
Mailing address:
  • Phone: 918-527-5360
  • Fax:

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: MRS. KASEY LYNN WICKBERG
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: M.S. CCC-SLP
Phone: 918-527-5360