MEDICARE: CANVAS CLINIC MANAGEMENT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1932972494
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANVAS CLINIC MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	5473 BLAIR RD STE 100
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-4227
Country	:	US
Telephone Number	:	817-394-2346
Fax Number	:	817-986-0540

Provider Business Practice Location Address
First Line	:	1550 NORWOOD DR STE 313
Second Line	:
City	:	HURST
State	:	TX
Zip	:	76054-3653
Country	:	US
Telephone Number	:	817-394-2346
Fax Number	:	817-986-0540

Authorized Official
Title or Position	:	FOUNDER/DIRECTOR
Name	:	MRS. ASHLEY STAFFORD
Credential	:	LCSW-S
Telephone Number	:	214-674-0798

Provider Enumeration Date	:	11/06/2023
Last Update Date	:	11/06/2023

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