Provider Demographics
NPI:1336576826
Name:BLUME, KOLLEEN (LPC)
Entity Type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:
Last Name:BLUME
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4434 N SACRAMENTO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3828
Mailing Address - Country:US
Mailing Address - Phone:773-251-0004
Mailing Address - Fax:773-267-4787
Practice Address - Street 1:2656 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1559
Practice Address - Country:US
Practice Address - Phone:773-267-5795
Practice Address - Fax:773-267-4787
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008456101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist