Healthcare Provider Details

I. General information

NPI: 1417661406
Provider Name (Legal Business Name): DANIELLE SEGERSTROM MA, NCC, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MONROE ST STE 23
BLOOMINGTON IL
61701-3955
US

IV. Provider business mailing address

200 W MONROE ST STE 23
BLOOMINGTON IL
61701-3955
US

V. Phone/Fax

Practice location:
  • Phone: 309-531-6107
  • Fax:
Mailing address:
  • Phone: 309-531-6107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.018505
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: