Healthcare Provider Details

I. General information

NPI: 1760386593
Provider Name (Legal Business Name): BLOOM BEAUTIFULLY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 BELLOWS WAY
VOLO IL
60073-8176
US

IV. Provider business mailing address

1075 BELLOWS WAY
VOLO IL
60073-8176
US

V. Phone/Fax

Practice location:
  • Phone: 224-201-6072
  • Fax:
Mailing address:
  • Phone: 224-201-6072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: SARA C OTTO
Title or Position: OWNER
Credential: MA, BCBA, LBA
Phone: 224-201-6072