Provider Demographics
NPI:1700354040
Name:BLOSSOM THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:BLOSSOM THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:541-604-0548
Mailing Address - Street 1:1757 NW FIELDS ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-7317
Mailing Address - Country:US
Mailing Address - Phone:541-604-0548
Mailing Address - Fax:541-668-6772
Practice Address - Street 1:408 NE HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4729
Practice Address - Country:US
Practice Address - Phone:541-617-8769
Practice Address - Fax:541-668-6772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty