Healthcare Provider Details

I. General information

NPI: 1629359872
Provider Name (Legal Business Name): THE LODGE COUNSELING & CONSULITING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 DOUGLAS ST SUITE # 208
SIOUX CITY IA
51101-1048
US

IV. Provider business mailing address

705 DOUGLAS ST SUITE # 208
SIOUX CITY IA
51101-1048
US

V. Phone/Fax

Practice location:
  • Phone: 712-259-5134
  • Fax:
Mailing address:
  • Phone: 712-259-5134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. VINCENT MAHON
Title or Position: CO-OWNER
Credential:
Phone: 712-259-5134