MEDICARE: BLOOM THERAPY CENTER OF ST. PETE, 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	SA8870	FL

General Provider Information

NPI Number	:	1982034963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOM THERAPY CENTER OF ST. PETE, LLC

Provider Business Mailing Address
First Line	:	5048 BEACH DR SE
Second Line	:	UNIT F
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33705-4832
Country	:	US
Telephone Number	:	850-748-1088
Fax Number	:

Provider Business Practice Location Address
First Line	:	5048 BEACH DR SE
Second Line	:	UNIT F
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33705-4832
Country	:	US
Telephone Number	:	850-748-1088
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	KATIE CHAMBERS
Credential	:	M.C.D., CCC/SLP
Telephone Number	:	850-748-1088

Provider Enumeration Date	:	11/12/2013
Last Update Date	:	11/12/2013

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