Provider Demographics
NPI:1356051866
Name:BLOSSOM COUNSELING AND TREATMENT CENTER, INC
Entity type:Organization
Organization Name:BLOSSOM COUNSELING AND TREATMENT CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:MUKWEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AIYUK
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:775-233-5409
Mailing Address - Street 1:304 S JONES BLVD STE 3501
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2623
Mailing Address - Country:US
Mailing Address - Phone:702-528-1099
Mailing Address - Fax:
Practice Address - Street 1:1627 E SOLANO DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2526
Practice Address - Country:US
Practice Address - Phone:702-528-1099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-25
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)