Provider Demographics
NPI:1336739176
Name:SPROUT GROW BLOSSOM LLC
Entity Type:Organization
Organization Name:SPROUT GROW BLOSSOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICKA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-634-7772
Mailing Address - Street 1:19 DOWNSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:FLANDERS
Mailing Address - State:NJ
Mailing Address - Zip Code:07836-9568
Mailing Address - Country:US
Mailing Address - Phone:973-634-7772
Mailing Address - Fax:
Practice Address - Street 1:19 DOWNSTREAM DR
Practice Address - Street 2:
Practice Address - City:FLANDERS
Practice Address - State:NJ
Practice Address - Zip Code:07836-9568
Practice Address - Country:US
Practice Address - Phone:973-634-7772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty