Healthcare Provider Details

I. General information

NPI: 1407546476
Provider Name (Legal Business Name): BLOOM ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 CLARINE DR
GOOSE CREEK SC
29445-3628
US

IV. Provider business mailing address

78 FOLLY ROAD BLVD STE B9
CHARLESTON SC
29407-7551
US

V. Phone/Fax

Practice location:
  • Phone: 336-918-6033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DR. BREANNAH DAVIS-BLOOM
Title or Position: OWNER OPERATOR
Credential: EDD
Phone: 336-918-6033