MEDICARE: BLOSSOM ABA THERAPY UT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1003643511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOSSOM ABA THERAPY UT LLC

Provider Business Mailing Address
First Line	:	229 ROUTE 70
Second Line	:
City	:	TOMS RIVER
State	:	NJ
Zip	:	08755
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2795 E COTTONWOOD PKWY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-7032
Country	:	US
Telephone Number	:	732-730-7505
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CHAD KAUFMAN
Credential	:
Telephone Number	:	917-538-7239

Provider Enumeration Date	:	09/18/2024
Last Update Date	:	09/18/2024

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