Provider Demographics
NPI:1568144723
Name:CANVAS OUTPATIENT, PLLC
Entity Type:Organization
Organization Name:CANVAS OUTPATIENT, PLLC
Other - Org Name:CANVAS OUTPATIENT, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-S
Authorized Official - Phone:214-674-0798
Mailing Address - Street 1:1550 NORWOOD DR STE 313
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3653
Mailing Address - Country:US
Mailing Address - Phone:817-394-2346
Mailing Address - Fax:817-986-0540
Practice Address - Street 1:1550 NORWOOD DR STE 313
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3653
Practice Address - Country:US
Practice Address - Phone:817-394-2346
Practice Address - Fax:817-986-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health