Provider Demographics
NPI:1427553627
Name:BLANK CANVAS COUNSELING CO
Entity Type:Organization
Organization Name:BLANK CANVAS COUNSELING CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KRING
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCPC
Authorized Official - Phone:815-592-4791
Mailing Address - Street 1:PO BOX 264
Mailing Address - Street 2:
Mailing Address - City:AROMA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60910-0264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:183 E BETHEL DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1456
Practice Address - Country:US
Practice Address - Phone:815-592-4791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)