Basic Information
| Provider Information | |||||||||
| NPI: | 1780188284 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLOSSOM | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435515267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193305122 | ||||||||
| FaxNumber: | 4199316820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1776 TREMAINSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436134039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192140606 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 06231989 | 05 | OH | MEDICAID |