Provider Demographics
NPI:1194059642
Name:BLOSSOM WHOLE FAMILY THERAPY & CHILD PSYCHOLOGY CENTER, PLLC
Entity type:Organization
Organization Name:BLOSSOM WHOLE FAMILY THERAPY & CHILD PSYCHOLOGY CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MANAGER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS-SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:612-719-5422
Mailing Address - Street 1:10505 WAYZATA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1507
Mailing Address - Country:US
Mailing Address - Phone:952-545-3300
Mailing Address - Fax:952-545-3300
Practice Address - Street 1:10505 WAYZATA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1507
Practice Address - Country:US
Practice Address - Phone:952-545-3300
Practice Address - Fax:952-545-3300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
MNLP4976261QM0801X, 261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health