Provider Demographics
NPI:1043057722
Name:BLOSSOM INTEGRATED HEALTH AND BEHAVIORAL SERVICES LLC
Entity type:Organization
Organization Name:BLOSSOM INTEGRATED HEALTH AND BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IHUOMA
Authorized Official - Middle Name:MARVELOUS
Authorized Official - Last Name:UDEAGHA
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:240-347-4494
Mailing Address - Street 1:338 MILL ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6138
Mailing Address - Country:US
Mailing Address - Phone:240-347-4494
Mailing Address - Fax:
Practice Address - Street 1:338 MILL ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6138
Practice Address - Country:US
Practice Address - Phone:240-347-4494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty