Provider Demographics
NPI:1730075474
Name:BLOOM SPEECH & NEURO REHAB, LLC
Entity type:Organization
Organization Name:BLOOM SPEECH & NEURO REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND SLP
Authorized Official - Prefix:
Authorized Official - First Name:ASHLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NIDIFFER-TULL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:918-869-6379
Mailing Address - Street 1:9422 S ELWOOD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2317
Mailing Address - Country:US
Mailing Address - Phone:918-869-6379
Mailing Address - Fax:918-627-7896
Practice Address - Street 1:9422 S ELWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2317
Practice Address - Country:US
Practice Address - Phone:918-869-6379
Practice Address - Fax:918-627-7896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech