Provider Demographics
NPI:1689166621
Name:BLOSSOM, LUNA L
Entity Type:Individual
Prefix:
First Name:LUNA
Middle Name:L
Last Name:BLOSSOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W 171ST ST APT 2K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3108
Mailing Address - Country:US
Mailing Address - Phone:360-688-9850
Mailing Address - Fax:
Practice Address - Street 1:1560 MAYFLOWER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5400
Practice Address - Country:US
Practice Address - Phone:718-948-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0225811225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist