Provider Demographics
NPI:1841929429
Name:BLOSSOM ABA THERAPY
Entity type:Organization
Organization Name:BLOSSOM ABA THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSHE
Authorized Official - Middle Name:NOSSON
Authorized Official - Last Name:JACOBOVITCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-215-6495
Mailing Address - Street 1:1910 PACIFIC AVE SUITE 2000-1359
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:75201
Mailing Address - Country:US
Mailing Address - Phone:216-215-6495
Mailing Address - Fax:
Practice Address - Street 1:1910 PACIFIC AVE SUITE 2000-1359
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:75201
Practice Address - Country:US
Practice Address - Phone:216-215-6495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health