Provider Demographics
NPI:1518742485
Name:WILLOW BLOOM THERAPY LLC
Entity Type:Organization
Organization Name:WILLOW BLOOM THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:WANDEMBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:575-571-0326
Mailing Address - Street 1:1070 BOLING LN
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-4868
Mailing Address - Country:US
Mailing Address - Phone:575-571-0326
Mailing Address - Fax:
Practice Address - Street 1:70 HORSESHOE CIR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-4579
Practice Address - Country:US
Practice Address - Phone:575-571-0326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty