=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922705243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INBLOOM THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2023
-----------------------------------------------------
Last Update Date | 02/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 E WATERSIDE DR UNIT 1012
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60601-0016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-688-9097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 E WATERSIDE DR UNIT 1012
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60601-0016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-688-9097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH THERAPIST
-----------------------------------------------------
Name | MS. KIMBERLY LOPEZ
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 773-808-0827
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------