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General NPI Number Information
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NPI Number | 1619784337
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Entity Type | Individual
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Provider Name | CHARLES JONATHAN BLIM
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Gender | Male
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Dates
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Enumeration Date | 12/16/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 2650 W MONTROSE AVE STE 102
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City | CHICAGO
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State | IL
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Zip | 60618-1562
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Country | US
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Telephone | 773-377-5261
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Fax | 872-813-4596
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Provider Business Mailing Address
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Address Line | 2650 W MONTROSE AVE STE 102
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City | CHICAGO
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State | IL
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Zip | 60618-1562
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Country | US
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Telephone | 773-377-5261
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Fax | 872-813-4596
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178021015
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License Number State | IL
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