Provider Demographics
NPI:1982034963
Name:BLOOM THERAPY CENTER OF ST. PETE, LLC
Entity Type:Organization
Organization Name:BLOOM THERAPY CENTER OF ST. PETE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:MCD, CCC/SLP
Authorized Official - Phone:850-748-1088
Mailing Address - Street 1:5048 BEACH DR SE
Mailing Address - Street 2:UNIT F
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-4832
Mailing Address - Country:US
Mailing Address - Phone:850-748-1088
Mailing Address - Fax:
Practice Address - Street 1:5048 BEACH DR SE
Practice Address - Street 2:UNIT F
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-4832
Practice Address - Country:US
Practice Address - Phone:850-748-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8870235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty