Basic Information
| Provider Information | |||||||||
| NPI: | 1801808696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLENDING FAMILIES, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600021542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478389904 | ||||||||
| FaxNumber: | 8478389907 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ANTIOCH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600021542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478389904 | ||||||||
| FaxNumber: | 8478389907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | ANGEL | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8478389904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | L.C.P.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 04932457 | 01 | IL | BLUE CROSS/SHIELD | OTHER |