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General NPI Number Information
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NPI Number | 1932950953
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Entity Type | Organization
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Legal Business Name | BLOSSOM & SPROUT WELLNESS, PLLC
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Dates
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Enumeration Date | 03/28/2024
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Last Update Date | 11/29/2024
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Provider Practice Location Address
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Address Line | 3238 GABRIEL AVE
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City | ZION
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State | IL
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Zip | 60099-3131
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Country | US
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Telephone | 224-788-0188
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Fax |
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Provider Business Mailing Address
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Address Line | 1713 GILBOA AVE
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City | ZION
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State | IL
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Zip | 60099-1618
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Country | US
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Telephone | 224-788-0188
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE CLINICAL DIRECTOR
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Name | LAFAY ERVING
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Credential | LCPC
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Telephone | 224-237-8037
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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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