Provider Demographics
NPI:1295416402
Name:BLOSSOM BRIDGE ABA LLC
Entity type:Organization
Organization Name:BLOSSOM BRIDGE ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD CERTIFIED BEHAVIOR ANALYST
Authorized Official - Prefix:DR
Authorized Official - First Name:SOON HWA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEOK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:785-505-0675
Mailing Address - Street 1:2015 AVENUE B APT B3
Mailing Address - Street 2:
Mailing Address - City:PLATTSMOUTH
Mailing Address - State:NE
Mailing Address - Zip Code:68048-1541
Mailing Address - Country:US
Mailing Address - Phone:785-505-0675
Mailing Address - Fax:
Practice Address - Street 1:2015 AVENUE B APT B3
Practice Address - Street 2:
Practice Address - City:PLATTSMOUTH
Practice Address - State:NE
Practice Address - Zip Code:68048-1541
Practice Address - Country:US
Practice Address - Phone:785-505-0675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty