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General NPI Number Information
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NPI Number | 1356184493
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Entity Type | Organization
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Legal Business Name | STILL I BLOOM LCSW
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Dates
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Enumeration Date | 06/17/2024
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Last Update Date | 06/17/2024
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Provider Practice Location Address
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Address Line | 107 WINNIE ST
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City | ALBANY
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State | NY
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Zip | 12208-2051
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Country | US
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Telephone | 518-487-9950
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Fax |
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Provider Business Mailing Address
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Address Line | 1060 BROADWAY # 1312
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City | MENANDS
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State | NY
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Zip | 12204-2507
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Country | US
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Telephone | 518-363-9288
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHENIQUE L BOUTELLE
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Credential | LCSW
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Telephone | 518-487-9950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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