=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104409580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY BLECHA LCPC, ATR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2021
-----------------------------------------------------
Last Update Date | 05/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1067 W SKYLARK DR
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60067-7058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-271-0226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1067 W SKYLARK DR
-----------------------------------------------------
City | PALATINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60067-7058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-271-0226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number | 16383
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180013092
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------