1396180659 NPI number — MICHIANA COUNSELING GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396180659 NPI number — MICHIANA COUNSELING GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHIANA COUNSELING GROUP, 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:
Provider Other Organization Name Type Code:
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:
1396180659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
56218 PARKWAY AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46516-9326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-293-0005
Provider Business Mailing Address Fax Number:
574-293-0019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
56218 PARKWAY AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46516-9326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-293-0005
Provider Business Practice Location Address Fax Number:
574-293-0019
Provider Enumeration Date:
04/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LALA
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
LICENSED CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
574-344-7941

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34003589A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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