Provider Demographics
NPI:1992240279
Name:CANVAS OF LIFE FAMILY COUNSELING SERVICES PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CANVAS OF LIFE FAMILY COUNSELING SERVICES PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:951-777-8176
Mailing Address - Street 1:6820 INDIANA AVE
Mailing Address - Street 2:STE. 240
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-7202
Mailing Address - Country:US
Mailing Address - Phone:951-777-8176
Mailing Address - Fax:951-888-9049
Practice Address - Street 1:6820 INDIANA AVE
Practice Address - Street 2:STE. 240
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-7202
Practice Address - Country:US
Practice Address - Phone:951-777-8176
Practice Address - Fax:951-888-9049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77468106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty