=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104790989
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOSSOM SERVICES GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2025
-----------------------------------------------------
Last Update Date | 10/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1042 14TH AVE E STE 210
-----------------------------------------------------
City | WEST FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58078-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-541-9884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2046 RUTTAN CT
-----------------------------------------------------
City | WEST FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58078-4258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-541-9884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/OWNER
-----------------------------------------------------
Name | SAHR THOMAS
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 701-541-8884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TM1800X
-----------------------------------------------------
Taxonomy Name | Intellectual & Developmental Disabilities Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------