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General NPI Number Information
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NPI Number | 1265824122
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Entity Type | Organization
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Legal Business Name | BLOOMINGTON COUNSELING AND WELLNESS SERVICES, LLC
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Dates
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Enumeration Date | 03/02/2015
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Last Update Date | 04/24/2024
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Provider Practice Location Address
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Address Line | 101 W KIRKWOOD AVE STE 103
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City | BLOOMINGTON
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State | IN
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Zip | 47404-6134
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Country | US
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Telephone | 812-633-9194
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Fax |
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Provider Business Mailing Address
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Address Line | 101 W KIRKWOOD AVE STE 103
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City | BLOOMINGTON
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State | IN
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Zip | 47404-6134
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | ROBERT QUINBY
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Credential | PH.D., HSPP
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Telephone | 812-633-9194
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20042834A
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License Number State | IN
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