Healthcare Provider Details

I. General information

NPI: 1790483055
Provider Name (Legal Business Name): CANVAS COUNSELING AND CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3575 BRIDGE RD STE 8 # 201
SUFFOLK VA
23435
US

IV. Provider business mailing address

3575 BRIDGE RD STE 8 #201
SUFFOLK VA
23435
US

V. Phone/Fax

Practice location:
  • Phone: 757-632-7107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL KITTRELL-JOHNSON
Title or Position: OWNER
Credential: PHD, LPC
Phone: 757-632-7107