Provider Demographics
NPI:1497036321
Name:DR. LARA BEANBLOSSOM, LLC
Entity Type:Organization
Organization Name:DR. LARA BEANBLOSSOM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEANBLOSSOM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:312-385-9777
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1004
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3402
Mailing Address - Country:US
Mailing Address - Phone:312-385-9777
Mailing Address - Fax:
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1004
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-385-9777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.006369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty