Basic Information
| Provider Information | |||||||||
| NPI: | 1386025484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLENDING FAMILIES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 800 MAIN ST | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600021542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478389904 | ||||||||
| FaxNumber: | 8478389907 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MAIN ST | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | ANTIOCH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600021542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478389904 | ||||||||
| FaxNumber: | 8478389907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2015 | ||||||||
| LastUpdateDate: | 06/15/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANGELL | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8478389904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 180005858 | IL | Y | Agencies | Community/Behavioral Health |
No ID Information.