| Organization Name: | BLOOM CENTER FOR PEDIATRIC THERAPY |
| NPI Number: | 1215397666 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MICHELLE LEE LANCE (OWNER/SPEECH LANGUAGE PATHOLOGIST) |
| Mailing Address: | 7677 W Portneuf Rd Pocatello |
| State: | ID US |
| Postal Code: | 832047336 |
| Phone Number: | 2086046260 |
| Fax Number: | |
| NPI Enumeration Date: | 02/27/2016 |
| NPI Last Update Date: | 04/04/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 235Z00000X |
| License Number: | SLP-2171 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Speech, Language and Hearing Service Providers |
| Taxonomy Classification: | Speech-Language Pathologist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A speech pathologist is a person qualified by a master |