Healthcare Provider Details

I. General information

NPI: 1265130587
Provider Name (Legal Business Name): CHILDREN OF PROMISE MENTORING PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 02/16/2023
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 5TH AVE SE STE 1200
CEDAR RAPIDS IA
52403-2428
US

IV. Provider business mailing address

1143 LONGFELLOW AVE
WATERLOO IA
50703-1720
US

V. Phone/Fax

Practice location:
  • Phone: 319-529-1543
  • Fax:
Mailing address:
  • Phone: 319-529-1543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. DANIEL PLEDGEJOHNSON
Title or Position: BEHAVIOR HEALTH COUNSELOR
Credential: MSW
Phone: 319-529-1543