Provider Demographics
NPI:1518558402
Name:BLOOM PEDIATRIC THERAPY
Entity Type:Organization
Organization Name:BLOOM PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:270-646-6393
Mailing Address - Street 1:722 LESLIE AVE
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-2115
Mailing Address - Country:US
Mailing Address - Phone:270-646-6393
Mailing Address - Fax:
Practice Address - Street 1:722 LESLIE AVE
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-2115
Practice Address - Country:US
Practice Address - Phone:270-646-6393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty