Provider Demographics
NPI:1104564384
Name:BLOOM SPEECH THERAPY
Entity type:Organization
Organization Name:BLOOM SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:OLIVIA
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP
Authorized Official - Phone:803-260-6253
Mailing Address - Street 1:PO BOX 90702
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29290-1702
Mailing Address - Country:US
Mailing Address - Phone:803-260-6253
Mailing Address - Fax:
Practice Address - Street 1:105 TOAD RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-3177
Practice Address - Country:US
Practice Address - Phone:803-260-6253
Practice Address - Fax:855-202-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No251J00000XAgenciesNursing CareGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1908Medicaid