Provider Demographics
NPI:1679125850
Name:BLOSSOM COMMUNITY SERVICES
Entity Type:Organization
Organization Name:BLOSSOM COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED SUBTANCE ABUSE CONSERLOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:DUNBAR
Authorized Official - Suffix:
Authorized Official - Credentials:PEER SUPPORT
Authorized Official - Phone:704-780-3082
Mailing Address - Street 1:3134 AUTEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-4599
Mailing Address - Country:US
Mailing Address - Phone:704-780-3082
Mailing Address - Fax:
Practice Address - Street 1:3134 AUTEN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-4599
Practice Address - Country:US
Practice Address - Phone:704-780-3082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental HealthGroup - Multi-Specialty