Provider Demographics
NPI:1093122426
Name:BLISS PRACTICE LLC
Entity Type:Organization
Organization Name:BLISS PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARI
Authorized Official - Middle Name:
Authorized Official - Last Name:WITTUM
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, MSCP
Authorized Official - Phone:630-377-7171
Mailing Address - Street 1:16 N RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1967
Mailing Address - Country:US
Mailing Address - Phone:630-377-7171
Mailing Address - Fax:630-584-8233
Practice Address - Street 1:16 N RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1967
Practice Address - Country:US
Practice Address - Phone:630-377-7171
Practice Address - Fax:630-584-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005941101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty