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General NPI Number Information
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NPI Number | 1104564384
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Entity Type | Organization
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Legal Business Name | BLOOM SPEECH THERAPY
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Dates
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Enumeration Date | 05/26/2022
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Last Update Date | 05/26/2022
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Provider Practice Location Address
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Address Line | 105 TOAD RD
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City | COLUMBIA
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State | SC
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Zip | 29209-3177
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Country | US
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Telephone | 803-260-6253
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Fax | 855-202-0515
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Provider Business Mailing Address
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Address Line | PO BOX 90702
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City | COLUMBIA
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State | SC
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Zip | 29290-1702
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Country | US
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Telephone | 803-260-6253
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. COURTNEY OLIVIA MARTIN
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Credential | MA,CCC-SLP
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Telephone | 803-260-6253
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QH0700X
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Taxonomy Name | Hearing and Speech Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QP0905X
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Taxonomy Name | State or Local Public Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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