Provider Demographics
NPI:1942922828
Name:BLOSSOM COUNSELING CENTER PLLC
Entity Type:Organization
Organization Name:BLOSSOM COUNSELING CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALENCIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SANDERS-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:910-442-6000
Mailing Address - Street 1:1030 LANTERNS LN
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9381
Mailing Address - Country:US
Mailing Address - Phone:910-442-6000
Mailing Address - Fax:
Practice Address - Street 1:1030 LANTERNS LN
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-9381
Practice Address - Country:US
Practice Address - Phone:910-442-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-16
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)