MEDICARE: MINDS IN BLOOM

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	103TC1900X	Counseling Psychologist

General Provider Information

NPI Number	:	1922878875
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDS IN BLOOM

Provider Business Mailing Address
First Line	:	2156 W 21ST PL APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-4010
Country	:	US
Telephone Number	:	312-847-4678
Fax Number	:

Provider Business Practice Location Address
First Line	:	2156 W 21ST PL APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-4010
Country	:	US
Telephone Number	:	312-847-4678
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER SPITLER
Credential	:
Telephone Number	:	312-847-4678

Provider Enumeration Date	:	01/02/2024
Last Update Date	:	01/02/2024

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Directions to “MINDS IN BLOOM ” Practice Location

Language	Start Address	Practice Location

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