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General NPI Number Information
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NPI Number | 1427553627
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Entity Type | Organization
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Legal Business Name | BLANK CANVAS COUNSELING CO
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Dates
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Enumeration Date | 03/28/2018
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Last Update Date | 03/28/2018
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Provider Practice Location Address
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Address Line | 183 E BETHEL DR
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City | BOURBONNAIS
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State | IL
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Zip | 60914-1456
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Country | US
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Telephone | 815-592-4791
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 264
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City | AROMA PARK
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State | IL
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Zip | 60910-0264
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | ROBERT KRING JR.
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Credential | LCPC
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Telephone | 815-592-4791
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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