Provider Demographics
NPI:1417643842
Name:BLOSSOM NP IN PSYCHIATRY HEALTH PLL
Entity Type:Organization
Organization Name:BLOSSOM NP IN PSYCHIATRY HEALTH PLL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALIYA
Authorized Official - Middle Name:ANOO
Authorized Official - Last Name:CHANDROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-214-0400
Mailing Address - Street 1:15-01 BROADWAY STE 24
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-6006
Mailing Address - Country:US
Mailing Address - Phone:833-325-6766
Mailing Address - Fax:
Practice Address - Street 1:15-01 BROADWAY STE 24
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-6006
Practice Address - Country:US
Practice Address - Phone:833-325-6766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty