=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225566268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOOMIVERSE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2017
-----------------------------------------------------
Last Update Date | 01/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7821 ERIE RD
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14047-9502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-549-0585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 ROVNER PL
-----------------------------------------------------
City | HAMBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14075-4205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MEGAN COLTONIAK
-----------------------------------------------------
Credential | MT-BC
-----------------------------------------------------
Telephone | 716-982-5170
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225A00000X
-----------------------------------------------------
Taxonomy Name | Music Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------