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General NPI Number Information
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NPI Number | 1194059642
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Entity Type | Organization
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Legal Business Name | BLOSSOM WHOLE FAMILY THERAPY & CHILD PSYCHOLOGY CENTER, PLLC
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Dates
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Enumeration Date | 09/30/2009
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Last Update Date | 08/28/2023
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Provider Practice Location Address
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Address Line | 10505 WAYZATA BLVD STE 103
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City | MINNETONKA
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State | MN
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Zip | 55305-1507
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Country | US
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Telephone | 952-545-3300
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Fax | 952-545-3300
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Provider Business Mailing Address
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Address Line | 10505 WAYZATA BLVD STE 103
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City | MINNETONKA
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State | MN
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Zip | 55305-1507
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Country | US
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Telephone | 952-545-3300
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Fax | 952-545-3300
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Authorized Official
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Title or Position | CHIEF MANAGER/PSYCHOLOGIST
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Name | DR. GRETCHEN LEWIS-SNYDER
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Credential | PHD, LP
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Telephone | 612-719-5422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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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 | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | LP4976
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | LP4976
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | LP4976
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License Number State | MN
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