Healthcare Provider Details

I. General information

NPI: 1265736110
Provider Name (Legal Business Name): BLUEPRINT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 BOULDER DRIVE SUITE B
URBANA IL
61802
US

IV. Provider business mailing address

2704 BOULDER DRIVE SUITE B
URBANA IL
61802
US

V. Phone/Fax

Practice location:
  • Phone: 217-469-9300
  • Fax: 217-469-9301
Mailing address:
  • Phone: 217-469-9300
  • Fax: 217-469-9301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.006836
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.009378
License Number StateIL

VIII. Authorized Official

Name: MS. GINA K JOHNSON
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 217-469-9300