Provider Demographics
NPI:1780188284
Name:BLOSSOM, AMANDA (QMHS)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5267
Mailing Address - Country:US
Mailing Address - Phone:419-330-5122
Mailing Address - Fax:419-931-6820
Practice Address - Street 1:1776 TREMAINSVILLE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613-4039
Practice Address - Country:US
Practice Address - Phone:419-214-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH06231989Medicaid