Provider Demographics
NPI:1750122198
Name:BLOSSOM WELL
Entity type:Organization
Organization Name:BLOSSOM WELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-632-1090
Mailing Address - Street 1:4193 W CRESTLINE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-2923
Mailing Address - Country:US
Mailing Address - Phone:708-632-1090
Mailing Address - Fax:
Practice Address - Street 1:142 W 62ND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3809
Practice Address - Country:US
Practice Address - Phone:708-632-1090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-31
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No171R00000XOther Service ProvidersInterpreterGroup - Multi-Specialty