Provider Demographics
NPI:1932773629
Name:BLOSSOM BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:BLOSSOM BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PRINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ETI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-992-2200
Mailing Address - Street 1:930 N MULLAN RD STE 1
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-4004
Mailing Address - Country:US
Mailing Address - Phone:509-596-1174
Mailing Address - Fax:
Practice Address - Street 1:930 N MULLAN RD STE 1
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4004
Practice Address - Country:US
Practice Address - Phone:509-596-1174
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-17
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty