Provider Demographics
NPI:1811964349
Name:BLOSSOM, LINDA (PT)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 LATONA RD
Mailing Address - Street 2:BLDG. C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-2700
Mailing Address - Country:US
Mailing Address - Phone:585-227-3140
Mailing Address - Fax:585-225-7681
Practice Address - Street 1:550 LATONA RD
Practice Address - Street 2:BLDG. C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-2700
Practice Address - Country:US
Practice Address - Phone:585-227-3140
Practice Address - Fax:585-225-7681
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006322174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC0770Medicare PIN