Provider Demographics
NPI:1164174694
Name:BLOSSOM SPEECH AND LANGUAGE THERAPY
Entity Type:Organization
Organization Name:BLOSSOM SPEECH AND LANGUAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:209-404-0333
Mailing Address - Street 1:5819 CHENAULT DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9621
Mailing Address - Country:US
Mailing Address - Phone:209-404-0333
Mailing Address - Fax:
Practice Address - Street 1:1101 STANDIFORD AVE STE A2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0981
Practice Address - Country:US
Practice Address - Phone:209-404-0333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty