MEDICARE: BLOOM PEDIATRIC 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	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1831767250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM PEDIATRIC THERAPY, LLC

Provider Business Mailing Address
First Line	:	1105 E VINE ST
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-3658
Country	:	US
Telephone Number	:	440-725-3948
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 AVALON RD
Second Line	:
City	:	MOUNT VERNON
State	:	OH
Zip	:	43050-1403
Country	:	US
Telephone Number	:	440-725-3948
Fax Number	:

Authorized Official
Title or Position	:	SPEECH LANGUAGE PATHOLOGIST
Name	:	KRISTEN CANTRELL
Credential	:	MA CCC-SLP
Telephone Number	:	740-358-0007

Provider Enumeration Date	:	06/13/2021
Last Update Date	:	12/21/2021

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Language	Start Address	Practice Location

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