Provider Demographics
NPI:1154194009
Name:BLOSSOM WORKS THERAPY LLC
Entity type:Organization
Organization Name:BLOSSOM WORKS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHATRECE
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-284-1033
Mailing Address - Street 1:4744 N ROYAL ATLANTA DR STE A
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3820
Mailing Address - Country:US
Mailing Address - Phone:770-284-1033
Mailing Address - Fax:470-523-4429
Practice Address - Street 1:4744 N ROYAL ATLANTA DR STE A
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3820
Practice Address - Country:US
Practice Address - Phone:770-284-1033
Practice Address - Fax:470-523-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-02
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty