1457737793 NPI number — FOUNDATIONS MENTAL HEALTH CENTER, LLC

Table of content: (NPI 1457737793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457737793 NPI number — FOUNDATIONS MENTAL HEALTH CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNDATIONS MENTAL HEALTH CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THERAPEUTIC REFLECTIONS, INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457737793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 S LAKEPORT ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
SIOUX CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51106-4543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-252-7170
Provider Business Mailing Address Fax Number:
712-252-7173

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 S LAKEPORT ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SIOUX CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51106-4543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-252-7170
Provider Business Practice Location Address Fax Number:
712-252-7173
Provider Enumeration Date:
08/10/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HECHT
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, CLINICAL DIRECTOR
Authorized Official Telephone Number:
712-252-7170

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  14090 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 072360 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 072360 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 600968049 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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