Provider Demographics
NPI:1275995128
Name:BLOOM WOMEN'S COUNSELING, LLC
Entity Type:Organization
Organization Name:BLOOM WOMEN'S COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON-GERHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT
Authorized Official - Phone:815-508-6936
Mailing Address - Street 1:122 S LOCUST ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-1865
Mailing Address - Country:US
Mailing Address - Phone:815-508-6936
Mailing Address - Fax:815-599-1380
Practice Address - Street 1:122 S LOCUST ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-1865
Practice Address - Country:US
Practice Address - Phone:815-508-6936
Practice Address - Fax:815-599-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-21
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000746106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty