Provider Demographics
NPI:1154891539
Name:BLOSSOM, T'ESSA LANAE (SLPA)
Entity type:Individual
Prefix:
First Name:T'ESSA
Middle Name:LANAE
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:T'ESSA
Other - Middle Name:LANAE
Other - Last Name:TOVOLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35105 KENAI SPUR HWY STE A
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7658
Mailing Address - Country:US
Mailing Address - Phone:907-260-7444
Mailing Address - Fax:
Practice Address - Street 1:35105 KENAI SPUR HWY STE A
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7658
Practice Address - Country:US
Practice Address - Phone:907-260-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1163362355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant