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General NPI Number Information
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NPI Number | 1366503138
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Entity Type | Individual
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Provider Name | LARRY E. BLOSSOM M.A.
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Gender | Male
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Dates
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Enumeration Date | 12/13/2006
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Last Update Date | 04/19/2022
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Provider Practice Location Address
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Address Line | 611 S UNION AVE APT A
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City | PUEBLO
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State | CO
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Zip | 81004-2250
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Country | US
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Telephone | 719-696-4252
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Fax |
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Provider Business Mailing Address
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Address Line | 3225 INDEPENDENCE RD
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City | CANON CITY
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State | CO
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Zip | 81212-9380
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Country | US
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Telephone | 719-275-2351
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Fax | 719-269-9386
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701002333
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License Number State | VA
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