Provider Demographics
NPI:1265736110
Name:BLUEPRINT
Entity type:Organization
Organization Name:BLUEPRINT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:217-469-9300
Mailing Address - Street 1:2704 BOULDER DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802
Mailing Address - Country:US
Mailing Address - Phone:217-469-9300
Mailing Address - Fax:217-469-9301
Practice Address - Street 1:2704 BOULDER DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802
Practice Address - Country:US
Practice Address - Phone:217-469-9300
Practice Address - Fax:217-469-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0093781041C0700X
IL180.006836101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty