Provider Demographics
NPI:1407546476
Name:BLOOM ABA
Entity Type:Organization
Organization Name:BLOOM ABA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BREANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS-BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:336-918-6033
Mailing Address - Street 1:78 FOLLY ROAD BLVD STE B9
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-7551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 CLARINE DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-3628
Practice Address - Country:US
Practice Address - Phone:336-918-6033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health