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General NPI Number Information
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NPI Number | 1356125041
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Entity Type | Organization
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Legal Business Name | BLOSSOM THERAPY SERVICES LLC
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Dates
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Enumeration Date | 08/23/2023
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Last Update Date | 08/23/2023
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Provider Practice Location Address
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Address Line | 38 CARRIAGE RD
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City | CHARLESTON
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State | WV
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Zip | 25314-2159
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Country | US
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Telephone | 202-681-7246
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Fax |
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Provider Business Mailing Address
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Address Line | 38 CARRIAGE RD
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City | CHARLESTON
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State | WV
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Zip | 25314-2159
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/BCBA
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Name | SHAWNA TYREE
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Credential |
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Telephone | 304-546-2463
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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