1619181757 NPI number — SUMMIT COUNSELING SERVICES PC

Table of content: (NPI 1619181757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619181757 NPI number — SUMMIT COUNSELING SERVICES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMMIT COUNSELING SERVICES PC
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:
1619181757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
53658 MARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46507-9710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-286-0030
Provider Business Mailing Address Fax Number:
574-234-1994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
928 E WAYNE ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46617-3024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-286-0030
Provider Business Practice Location Address Fax Number:
574-234-1994
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRYANT
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT - OWNER
Authorized Official Telephone Number:
574-286-0030

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  20010389A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: 34004946A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: 34004850A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 000000373890 . This is a "ANTHEM GROUP NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000373892 . This is a "ANTHEM INDIV PROVIDER #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000393533 . This is a "ANTHEM INDIV PROVIDER #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000485220 . This is a "ANTHEM INDIV PROVIDER #" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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