Provider Demographics
NPI:1366503138
Name:BLOSSOM, LARRY E (MA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:E
Last Name:BLOSSOM
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9380
Mailing Address - Country:US
Mailing Address - Phone:719-275-2351
Mailing Address - Fax:719-269-9386
Practice Address - Street 1:611 S UNION AVE APT A
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2250
Practice Address - Country:US
Practice Address - Phone:719-696-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701002333101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5409152Medicaid
VA5409179Medicaid