1093221467 NPI number — BLOSSOM PEDIATRIC SPEECH THERAPY

Table of content: (NPI 1093221467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093221467 NPI number — BLOSSOM PEDIATRIC SPEECH THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLOSSOM PEDIATRIC SPEECH THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093221467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1796 NORTHSTAR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PETALUMA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94954-6663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-643-7126
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1796 NORTHSTAR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PETALUMA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94954-6663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-559-8308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WELENSKY
Authorized Official First Name:
ANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
SPEECH-LANGUAGE PATHOLOGIST, OWNER
Authorized Official Telephone Number:
707-559-8308

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  14047001 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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