=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780287425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOSSOMING ESSENCE COUNSELING COACHING & CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2020
-----------------------------------------------------
Last Update Date | 11/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15202 NW 147TH DR STE 1200 #176
-----------------------------------------------------
City | ALACHUA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32615-5336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-672-1214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15202 NW 147TH DR STE 1200
-----------------------------------------------------
City | ALACHUA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32615-5336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-672-1214
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING OWNER
-----------------------------------------------------
Name | MARQUETTA LEE
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 352-672-1214
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------