=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083309652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DORENE ROSENBLOOM-MIRMAN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2023
-----------------------------------------------------
Last Update Date | 04/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 910 SKOKIE BLVD STE 215
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-4033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-902-2199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2206 KIPLING LN
-----------------------------------------------------
City | HIGHLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60035-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-902-2199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 178.014724
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------