Provider Demographics
NPI:1568097186
Name:BLOSSOM PSYCHOTHERAPY AND SERVICES
Entity Type:Organization
Organization Name:BLOSSOM PSYCHOTHERAPY AND SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MASCARENBAS
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:909-681-7858
Mailing Address - Street 1:8344 HEATHER AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-8070
Mailing Address - Country:US
Mailing Address - Phone:909-681-7858
Mailing Address - Fax:
Practice Address - Street 1:8608 UTICA AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4877
Practice Address - Country:US
Practice Address - Phone:909-681-7858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty