Provider Demographics
NPI:1427184795
Name:BEANBLOSSOM, K. LARA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:K. LARA
Middle Name:
Last Name:BEANBLOSSOM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KATHARINE
Other - Middle Name:LARA
Other - Last Name:BEANBLOSSOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:STE 901
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3767
Mailing Address - Country:US
Mailing Address - Phone:312-385-9777
Mailing Address - Fax:
Practice Address - Street 1:545 LINCOLN AVE STE 4
Practice Address - Street 2:
Practice Address - City:WINNETKA
Practice Address - State:IL
Practice Address - Zip Code:60093-2349
Practice Address - Country:US
Practice Address - Phone:312-385-9777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
K13676Medicare ID - Type Unspecified