MEDICARE: CANVAS OF LIFE FAMILY COUNSELING SERVICES PROFESSIONAL CORPORATION

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	106H00000X	Marriage & Family Therapist	77468	CA

General Provider Information

NPI Number	:	1992240279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANVAS OF LIFE FAMILY COUNSELING SERVICES PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	6820 INDIANA AVE
Second Line	:	STE. 240
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-7202
Country	:	US
Telephone Number	:	951-777-8176
Fax Number	:	951-888-9049

Provider Business Practice Location Address
First Line	:	6820 INDIANA AVE
Second Line	:	STE. 240
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-7202
Country	:	US
Telephone Number	:	951-777-8176
Fax Number	:	951-888-9049

Authorized Official
Title or Position	:	DIRECTOR
Name	:	LISA M CARRILLO
Credential	:	LMFT
Telephone Number	:	951-777-8176

Provider Enumeration Date	:	12/22/2016
Last Update Date	:	12/22/2016

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