Provider Demographics
NPI:1295329654
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/BCBA
Authorized Official - Prefix:MS
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LAVIGNE
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:573-480-0440
Mailing Address - Street 1:901 W 14TH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-4198
Mailing Address - Country:US
Mailing Address - Phone:636-432-6709
Mailing Address - Fax:636-432-1559
Practice Address - Street 1:910 W 14TH ST STE 230
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-7003
Practice Address - Country:US
Practice Address - Phone:573-480-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-25
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty