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General NPI Number Information
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NPI Number | 1457080301
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Entity Type | Organization
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Legal Business Name | INNERBLOOM THERAPY PRACTICE PC
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Dates
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Enumeration Date | 06/07/2022
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Last Update Date | 08/08/2023
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Provider Practice Location Address
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Address Line | 2656 W MONTROSE AVENUE SUITE 104
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City | CHICAGO
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State | IL
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Zip | 60618
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Country | US
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Telephone | 773-969-6030
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Fax |
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Provider Business Mailing Address
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Address Line | 1235 N CLYBOURN AVE SUITE A BOX 222
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City | CHICAGO
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State | IL
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Zip | 60610
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Country | US
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Telephone | 773-969-6030
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. DENISE LYNN GULOTTA
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Credential | LCSW
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Telephone | 773-969-6030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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