MEDICARE: PROVIDENCE COUNSELING CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34004602A	IN

General Provider Information

NPI Number	:	1174619654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE COUNSELING CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 5622
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46895-5622
Country	:	US
Telephone Number	:	260-418-6765
Fax Number	:	260-416-0601

Provider Business Practice Location Address
First Line	:	10305 DAWSONS CREEK BLVD
Second Line	:	SUITE C
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1914
Country	:	US
Telephone Number	:	260-418-6765
Fax Number	:	260-416-0601

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MS. C LAUDIA D DAVIS
Credential	:	MSW, LCSW
Telephone Number	:	260-418-6765

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	08/22/2020

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