Provider Demographics
NPI:1235720244
Name:BLOSSOM PROFESSIONAL PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:BLOSSOM PROFESSIONAL PSYCHOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRNA
Authorized Official - Middle Name:T
Authorized Official - Last Name:MERINO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:805-666-9032
Mailing Address - Street 1:3652 JELLYFISH LN
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035-3049
Mailing Address - Country:US
Mailing Address - Phone:805-666-9032
Mailing Address - Fax:
Practice Address - Street 1:3652 JELLYFISH LN
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93035-3049
Practice Address - Country:US
Practice Address - Phone:805-666-9032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty