Provider Demographics
NPI:1770101784
Name:BLAZING TRAILS COUNSELING, PLLC
Entity type:Organization
Organization Name:BLAZING TRAILS COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC, NCC
Authorized Official - Phone:779-435-4271
Mailing Address - Street 1:15941 HARLEM AVE # 140
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1609
Mailing Address - Country:US
Mailing Address - Phone:779-435-4271
Mailing Address - Fax:
Practice Address - Street 1:15941 HARLEM AVE # 140
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1609
Practice Address - Country:US
Practice Address - Phone:779-435-4271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-07
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty