Basic Information
| Provider Information | |||||||||
| NPI: | 1366503138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOSSOM | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3225 INDEPENDENCE RD | ||||||||
| Address2: | |||||||||
| City: | CANON CITY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812129380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192752351 | ||||||||
| FaxNumber: | 7192699386 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 S UNION AVE APT A | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196964252 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 0701002333 | VA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 5409152 | 05 | VA | MEDICAID | 5409179 | 05 | VA | MEDICAID |