Healthcare Provider Details

I. General information

NPI: 1881741593
Provider Name (Legal Business Name): FOUNDATION 2, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 JOHNSON AVE NW
CEDAR RAPIDS IA
52405-4865
US

IV. Provider business mailing address

1714 JOHNSON AVE NW
CEDAR RAPIDS IA
52405-4865
US

V. Phone/Fax

Practice location:
  • Phone: 319-362-1170
  • Fax: 319-297-7406
Mailing address:
  • Phone: 319-362-1170
  • Fax: 319-297-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number1103135
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier1103135
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: PATRICIA GILBAUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: MSW
Phone: 319-362-1170