Provider Demographics
NPI:1477303006
Name:BLOSSOM ABA THERAPY NC
Entity Type:Organization
Organization Name:BLOSSOM ABA THERAPY NC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-538-7239
Mailing Address - Street 1:322 LAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2436
Mailing Address - Country:US
Mailing Address - Phone:732-730-7505
Mailing Address - Fax:
Practice Address - Street 1:322 LAMAR AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2436
Practice Address - Country:US
Practice Address - Phone:732-730-7505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-26
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty