Basic Information
| Provider Information | |||||||||
| NPI: | 1265626865 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLENDING FAMILIES, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 800 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478389904 | ||||||||
| FaxNumber: | 8478389907 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478389904 | ||||||||
| FaxNumber: | 8478389907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 08/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | GIERNOTH | ||||||||
| AuthorizedOfficialFirstName: | JANEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8478389904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1063519510 | 01 | IL | LCPC | OTHER | 1457579625 | 01 | IL | LCPC | OTHER | 1023020815 | 01 | IL | LCPC | OTHER | 1902927791 | 01 | IL | LCPC | OTHER |