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General NPI Number Information
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NPI Number | 1275453292
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Entity Type | Organization
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Legal Business Name | BLOOM PEDIATRIC SPEECH LLC
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Dates
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Enumeration Date | 07/20/2026
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Last Update Date | 07/20/2026
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Provider Practice Location Address
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Address Line | 2000 NW 150TH ST
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City | OKLAHOMA CITY
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State | OK
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Zip | 73134-2004
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Country | US
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Telephone | 918-527-5360
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Fax |
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Provider Business Mailing Address
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Address Line | 14820 MARBLELEAF DR
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City | EDMOND
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State | OK
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Zip | 73013-1468
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Country | US
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Telephone | 918-527-5360
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Fax |
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Authorized Official
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Title or Position | SPEECH LANGUAGE PATHOLOGIST
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Name | MRS. KASEY LYNN WICKBERG
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Credential | M.S. CCC-SLP
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Telephone | 918-527-5360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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