Provider Demographics
NPI:1033839717
Name:BLOOM ABA THERAPY PLLC
Entity Type:Organization
Organization Name:BLOOM ABA THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-366-9675
Mailing Address - Street 1:201 QUAKER LN
Mailing Address - Street 2:
Mailing Address - City:DELANSON
Mailing Address - State:NY
Mailing Address - Zip Code:12053-2833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 QUAKER LN
Practice Address - Street 2:
Practice Address - City:DELANSON
Practice Address - State:NY
Practice Address - Zip Code:12053-2833
Practice Address - Country:US
Practice Address - Phone:518-366-9675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health