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General NPI Number Information
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NPI Number | 1336301894
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Entity Type | Organization
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Legal Business Name | BLOSSOM TOWNE ENTERPRISES
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Dates
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Enumeration Date | 06/26/2008
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Last Update Date | 06/26/2008
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Provider Practice Location Address
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Address Line | 8615 EAGLE POINT BLVD
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City | LAKE ELMO
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State | MN
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Zip | 55042-8628
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Country | US
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Telephone | 651-264-0444
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Fax | 651-264-0447
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Provider Business Mailing Address
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Address Line | 8615 EAGLE POINT BLVD
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City | LAKE ELMO
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State | MN
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Zip | 55042-8628
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Country | US
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Telephone | 651-264-0444
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Fax | 651-264-0447
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. SHARON BLOSSOM
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Credential |
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Telephone | 651-264-0444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP-1196
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License Number State | MN
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