Provider Demographics
NPI:1619674124
Name:BLOOM PEDIATRIC THERAPY LLC
Entity Type:Organization
Organization Name:BLOOM PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:HURD
Authorized Official - Suffix:
Authorized Official - Credentials:MSOT, OTR/L
Authorized Official - Phone:678-967-1924
Mailing Address - Street 1:136 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILNER
Mailing Address - State:GA
Mailing Address - Zip Code:30257-3844
Mailing Address - Country:US
Mailing Address - Phone:678-967-1924
Mailing Address - Fax:
Practice Address - Street 1:14557 HIGHWAY 19 STE C
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-9582
Practice Address - Country:US
Practice Address - Phone:678-967-1924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty