1285111278 NPI number — HEALING YOUR JOURNEY THERAPY, LLC

Table of content: (NPI 1285111278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285111278 NPI number — HEALING YOUR JOURNEY THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALING YOUR JOURNEY THERAPY, 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:
1285111278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 DONMOYER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46614-1864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-319-1653
Provider Business Mailing Address Fax Number:
574-406-7966

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 W MCKINLEY AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46545-5564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-319-1653
Provider Business Practice Location Address Fax Number:
574-406-7966
Provider Enumeration Date:
07/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DELCOURT
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
SOLE MEMBER/PRESIDENT
Authorized Official Telephone Number:
574-850-4267

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34007827A , 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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