=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174339030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOSSOM ABA THERAPY CO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2024
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 N SHERMAN ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80203-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-327-5283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 229 ROUTE 70
-----------------------------------------------------
City | TOMS RIVER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08755-1026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CHAIM KAUFMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 857-327-5283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------