Provider Demographics
NPI:1275321796
Name:BLACK LOTUS COUNSELING CENTER
Entity type:Organization
Organization Name:BLACK LOTUS COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:E
Authorized Official - Last Name:SPRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-993-8724
Mailing Address - Street 1:2431 BETHANY RD STE B
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3136
Mailing Address - Country:US
Mailing Address - Phone:815-993-8724
Mailing Address - Fax:
Practice Address - Street 1:2431 BETHANY RD STE B
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3136
Practice Address - Country:US
Practice Address - Phone:815-993-8724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health