Provider Demographics
NPI:1518309384
Name:WASHINGTON, BLOSSOM ELEITHIA
Entity Type:Individual
Prefix:MRS
First Name:BLOSSOM
Middle Name:ELEITHIA
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4156 BROWNWOOD LN NW
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-4501
Mailing Address - Country:US
Mailing Address - Phone:516-662-6709
Mailing Address - Fax:
Practice Address - Street 1:700 CHURCH ST N
Practice Address - Street 2:SUITE 70
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4379
Practice Address - Country:US
Practice Address - Phone:704-918-1343
Practice Address - Fax:704-461-4334
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5659225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist