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General NPI Number Information
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NPI Number | 1275995128
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Entity Type | Organization
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Legal Business Name | BLOOM WOMEN'S COUNSELING, LLC
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Dates
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Enumeration Date | 03/21/2016
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Last Update Date | 03/21/2016
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Provider Practice Location Address
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Address Line | 122 S LOCUST ST SUITE 5
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City | SYCAMORE
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State | IL
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Zip | 60178-1865
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Country | US
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Telephone | 815-508-6936
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Fax | 815-599-1380
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Provider Business Mailing Address
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Address Line | 122 S LOCUST ST SUITE 5
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City | SYCAMORE
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State | IL
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Zip | 60178-1865
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Country | US
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Telephone | 815-508-6936
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Fax | 815-599-1380
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | STEPHANIE NELSON-GERHARDT
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Credential | M.S., LMFT
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Telephone | 815-508-6936
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 166.000746
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License Number State | IL
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