Provider Demographics
NPI:1770853939
Name:BLOOM BEHAVIOR THERAPY LLC
Entity Type:Organization
Organization Name:BLOOM BEHAVIOR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:NASTALLY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA-D, LBA
Authorized Official - Phone:270-908-0461
Mailing Address - Street 1:6201 BENTON RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-1304
Mailing Address - Country:US
Mailing Address - Phone:270-908-0461
Mailing Address - Fax:270-366-0780
Practice Address - Street 1:6201 BENTON RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-1304
Practice Address - Country:US
Practice Address - Phone:270-908-0461
Practice Address - Fax:270-366-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-05
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0016103K00000X
251C00000X
KY800217251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty