Healthcare Provider Details

I. General information

NPI: 1104564384
Provider Name (Legal Business Name): BLOOM SPEECH THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 TOAD RD
COLUMBIA SC
29209-3177
US

IV. Provider business mailing address

PO BOX 90702
COLUMBIA SC
29290-1702
US

V. Phone/Fax

Practice location:
  • Phone: 803-260-6253
  • Fax: 855-202-0515
Mailing address:
  • Phone: 803-260-6253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. COURTNEY OLIVIA MARTIN
Title or Position: PRESIDENT
Credential: MA,CCC-SLP
Phone: 803-260-6253