Provider Demographics
NPI:1447753082
Name:BLOSSOM BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:BLOSSOM BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FITTERER
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, LBA
Authorized Official - Phone:757-524-2510
Mailing Address - Street 1:763 J CLYDE MORRIS BLVD STE 1C
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:763 J CLYDE MORRIS BLVD STE 1C
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1533
Practice Address - Country:US
Practice Address - Phone:757-524-2510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-09
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty