Provider Demographics
NPI:1225794761
Name:SUPER BLOOM COUNSELING LLC
Entity Type:Organization
Organization Name:SUPER BLOOM COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:SON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:270-873-9007
Mailing Address - Street 1:1408 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-3616
Mailing Address - Country:US
Mailing Address - Phone:270-873-9007
Mailing Address - Fax:
Practice Address - Street 1:1408 MARTIN DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-3616
Practice Address - Country:US
Practice Address - Phone:270-873-9007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty