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General NPI Number Information
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NPI Number | 1487435236
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Entity Type | Organization
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Legal Business Name | INBLOOM AUTISM
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Dates
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Enumeration Date | 10/09/2023
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Last Update Date | 10/09/2023
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Provider Practice Location Address
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Address Line | 200 N PATRICK BLVD STE
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City | BROOKFIELD
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State | WI
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Zip | 53045-5883
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Country | US
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Telephone | 888-754-0398
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Fax |
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Provider Business Mailing Address
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Address Line | 1363 N 40TH ST APT 5
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City | MILWAUKEE
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State | WI
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Zip | 53208-2857
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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 | BEHAVIOR THERAPIST
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Name | MYA EDWARDS
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Credential |
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Telephone | 920-512-4890
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2055X
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Taxonomy Name | Child Mental Illness Respite Care
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License Number |
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License Number State |
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