Provider Demographics
NPI:1912572330
Name:BLOSSOM BEHAVIORAL SERVICES LLC
Entity Type:Organization
Organization Name:BLOSSOM BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUARES
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:954-882-2142
Mailing Address - Street 1:4263 NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-5028
Mailing Address - Country:US
Mailing Address - Phone:954-882-2142
Mailing Address - Fax:
Practice Address - Street 1:4263 NEVADA ST
Practice Address - Street 2:
Practice Address - City:AVE MARIA
Practice Address - State:FL
Practice Address - Zip Code:34142-5028
Practice Address - Country:US
Practice Address - Phone:954-882-2142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and SpeechGroup - Multi-Specialty