Healthcare Provider Details

I. General information

NPI: 1093546954
Provider Name (Legal Business Name): BLOOM SPEECH & LANGUAGE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 HIGHWAY 326 S
SOUR LAKE TX
77659-7871
US

IV. Provider business mailing address

PO BOX 310
NOME TX
77629-0310
US

V. Phone/Fax

Practice location:
  • Phone: 409-659-2076
  • Fax:
Mailing address:
  • Phone: 409-659-2076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR BLEDSOE
Title or Position: OWNER
Credential:
Phone: 409-659-2076