Provider Demographics
NPI:1356184493
Name:STILL I BLOOM LCSW
Entity type:Organization
Organization Name:STILL I BLOOM LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHENIQUE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOUTELLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:518-487-9950
Mailing Address - Street 1:1060 BROADWAY # 1312
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-2507
Mailing Address - Country:US
Mailing Address - Phone:518-363-9288
Mailing Address - Fax:
Practice Address - Street 1:107 WINNIE ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-2051
Practice Address - Country:US
Practice Address - Phone:518-487-9950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)