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General NPI Number Information
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NPI Number | 1306503644
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Entity Type | Organization
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Legal Business Name | PATHWAYS IN BLOOM PSYCHOLOGICAL SERVICES, LLC
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Dates
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Enumeration Date | 11/22/2021
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Last Update Date | 04/12/2024
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Provider Practice Location Address
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Address Line | 625 COMMERCE DRIVE SUITE 104
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City | LAKELAND
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State | FL
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Zip | 33813
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Country | US
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Telephone | 702-326-6959
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Fax |
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Provider Business Mailing Address
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Address Line | 13194 US HIGHWAY 301 S # 272
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City | RIVERVIEW
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State | FL
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Zip | 33578-7410
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Country | US
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Telephone | 702-326-6959
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Fax |
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Authorized Official
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Title or Position | OWNER/LICENSED CLINICAL PSYCHOLOGIS
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Name | DR. DANIELLA MARIE VASQUEZ
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Credential | PSY.D.
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Telephone | 813-436-3588
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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