Provider Demographics
NPI:1093221467
Name:BLOSSOM PEDIATRIC SPEECH THERAPY
Entity Type:Organization
Organization Name:BLOSSOM PEDIATRIC SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELENSKY
Authorized Official - Suffix:
Authorized Official - Credentials:MCD, CCC-SLP
Authorized Official - Phone:707-559-8308
Mailing Address - Street 1:1796 NORTHSTAR DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6663
Mailing Address - Country:US
Mailing Address - Phone:404-643-7126
Mailing Address - Fax:
Practice Address - Street 1:1796 NORTHSTAR DR
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6663
Practice Address - Country:US
Practice Address - Phone:707-559-8308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2017-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14047001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty