Healthcare Provider Details

I. General information

NPI: 1427761824
Provider Name (Legal Business Name): DYLAN GABRIEL BLOOM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2022
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15724 S ROUTE 59 STE 102
PLAINFIELD IL
60544-2806
US

IV. Provider business mailing address

15724 S ROUTE 59 STE 102
PLAINFIELD IL
60544-2806
US

V. Phone/Fax

Practice location:
  • Phone: 630-527-8877
  • Fax: 630-527-8877
Mailing address:
  • Phone: 630-527-8877
  • Fax: 630-527-8877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149032201
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: