Healthcare Provider Details

I. General information

NPI: 1932945243
Provider Name (Legal Business Name): BLYSSS BEHAVIORAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2024
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9415 S WESTERN AVE # 206
CHICAGO IL
60643-6700
US

IV. Provider business mailing address

900 W SUNSET DR APT 613
GLENWOOD IL
60425-1159
US

V. Phone/Fax

Practice location:
  • Phone: 708-941-7448
  • Fax:
Mailing address:
  • Phone: 844-425-9777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CORY R WILLLIAMS
Title or Position: MANAGING PARTNER
Credential: DNP
Phone: 844-425-9777