=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831469824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAND & ASSOCIATES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2012
-----------------------------------------------------
Last Update Date | 02/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 856 W BUENA AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-404-8161
-----------------------------------------------------
Fax | 773-404-8162
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 856 W BUENA AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60613-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-404-8161
-----------------------------------------------------
Fax | 773-404-8162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MICHAEL J BLAND
-----------------------------------------------------
Credential | PSY,D., D.MIN., LCPC
-----------------------------------------------------
Telephone | 773-404-8161
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180003122
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------