Healthcare Provider Details

I. General information

NPI: 1568386472
Provider Name (Legal Business Name): BLOOM BEHAVIOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4923 N RIDGEWAY AVE APT 2
CHICAGO IL
60625-0926
US

IV. Provider business mailing address

4923 N RIDGEWAY AVE APT 2
CHICAGO IL
60625-0926
US

V. Phone/Fax

Practice location:
  • Phone: 815-342-8932
  • Fax:
Mailing address:
  • Phone: 815-342-8932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRIANNA CAMPBELL
Title or Position: BOARD-CERTIFIED BEHAVIOR ANALYST
Credential: M.ED., BCBA, LBA
Phone: 815-342-8932