MEDICARE: BLOOMING MINDS BEHAVIORAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1598621302
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLOOMING MINDS BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	11252 S SACRAMENTO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2302
Country	:	US
Telephone Number	:	239-944-1670
Fax Number	:

Provider Business Practice Location Address
First Line	:	11252 S SACRAMENTO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60655-2302
Country	:	US
Telephone Number	:	239-944-1670
Fax Number	:

Authorized Official
Title or Position	:	BCBA
Name	:	KATYA LOPEZ
Credential	:	M.A., BCBA, LBA
Telephone Number	:	239-944-1670

Provider Enumeration Date	:	12/25/2025
Last Update Date	:	12/25/2025

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