MEDICARE: BALANCE AND BLOSSOM THERAPY PLLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1902634934
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BALANCE AND BLOSSOM THERAPY PLLC

Provider Business Mailing Address
First Line	:	511 EICHLER DR STE 204
Second Line	:
City	:	WEST DUNDEE
State	:	IL
Zip	:	60118-2767
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 EICHLER DR STE 204
Second Line	:
City	:	WEST DUNDEE
State	:	IL
Zip	:	60118-2767
Country	:	US
Telephone Number	:	630-479-1788
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JESSICA SMITH
Credential	:	LCSW
Telephone Number	:	630-479-1788

Provider Enumeration Date	:	07/22/2024
Last Update Date	:	07/22/2024

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