Provider Demographics
NPI:1578303889
Name:BLOOM THERAPY SERVICES
Entity type:Organization
Organization Name:BLOOM THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-904-3412
Mailing Address - Street 1:3311 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-4103
Mailing Address - Country:US
Mailing Address - Phone:870-904-3412
Mailing Address - Fax:
Practice Address - Street 1:3311 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-4103
Practice Address - Country:US
Practice Address - Phone:870-904-3412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2445243Medicaid