Provider Demographics
NPI:1790291649
Name:BLOOM BEHAVIOR SERVICES LLC
Entity Type:Organization
Organization Name:BLOOM BEHAVIOR SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAI
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:BCABA
Authorized Official - Phone:407-758-4948
Mailing Address - Street 1:6903 SAWTOOTH CT
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-8451
Mailing Address - Country:US
Mailing Address - Phone:407-758-4948
Mailing Address - Fax:321-244-0645
Practice Address - Street 1:6903 SAWTOOTH CT
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-8451
Practice Address - Country:US
Practice Address - Phone:407-758-4948
Practice Address - Fax:321-244-0645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018854500Medicaid