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NPI Code Detail

MEDICARE: BLOOM BEHAVIOR THERAPY LLC

MEDICARE: BLOOM BEHAVIOR 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
1103K00000XBehavior AnalystKY-0016KY
2251C00000XDevelopmentally Disabled Services Day Training Agency
3251S00000XCommunity/Behavioral Health Agency800217KY

General Provider Information

NPI Number : 1770853939
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLOOM BEHAVIOR THERAPY LLC
Provider Business Mailing Address
First Line : 6201 BENTON RD
Second Line :
City : PADUCAH
State : KY
Zip : 42003-1304
Country : US
Telephone Number : 270-908-0461
Fax Number : 270-366-0780
Provider Business Practice Location Address
First Line : 6201 BENTON RD
Second Line :
City : PADUCAH
State : KY
Zip : 42003-1304
Country : US
Telephone Number : 270-908-0461
Fax Number : 270-366-0780
Authorized Official
Title or Position : OWNER
Name : BECKY L NASTALLY
Credential : PHD, BCBA-D, LBA
Telephone Number : 270-908-0461
Provider Enumeration Date : 01/05/2012
Last Update Date : 07/08/2021

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