MEDICARE: BLOSSOM BEYOND THERAPY 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1285465971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOSSOM BEYOND THERAPY LLC

Provider Business Mailing Address
First Line	:	77 RIDGE RD APT 204
Second Line	:
City	:	NORTH ARLINGTON
State	:	NJ
Zip	:	07031-6475
Country	:	US
Telephone Number	:	201-429-5404
Fax Number	:

Provider Business Practice Location Address
First Line	:	77 RIDGE RD APT 204
Second Line	:
City	:	NORTH ARLINGTON
State	:	NJ
Zip	:	07031-6475
Country	:	US
Telephone Number	:	201-429-5404
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEMI BAKARE
Credential	:
Telephone Number	:	201-429-5404

Provider Enumeration Date	:	08/13/2024
Last Update Date	:	08/13/2024

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Directions to “BLOSSOM BEYOND THERAPY LLC ” Practice Location

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