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General NPI Number Information
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NPI Number | 1679371058
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Entity Type | Organization
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Legal Business Name | BLOSSOM FAMILY THERAPY PLLC
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Dates
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Enumeration Date | 03/03/2025
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Last Update Date | 05/27/2025
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Provider Practice Location Address
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Address Line | 13420 REESE BLVD W
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City | HUNTERSVILLE
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State | NC
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Zip | 28078-7925
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Country | US
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Telephone | 980-297-8237
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Fax | 704-887-9496
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Provider Business Mailing Address
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Address Line | 13420 REESE BLVD W
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City | HUNTERSVILLE
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State | NC
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Zip | 28078-7925
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Country | US
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Telephone | 980-297-8237
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Fax | 704-887-9496
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Authorized Official
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Title or Position | OWNER
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Name | SHACOYA GHRAHAM
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Credential |
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Telephone | 980-297-8237
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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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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