Healthcare Provider Details

I. General information

NPI: 1457737793
Provider Name (Legal Business Name): FOUNDATIONS MENTAL HEALTH CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 S LAKEPORT ST SUITE B
SIOUX CITY IA
51106-4543
US

IV. Provider business mailing address

3450 S LAKEPORT ST SUITE B
SIOUX CITY IA
51106-4543
US

V. Phone/Fax

Practice location:
  • Phone: 712-252-7170
  • Fax: 712-252-7173
Mailing address:
  • Phone: 712-252-7170
  • Fax: 712-252-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14090
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number072360
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number072360
License Number StateIA

VII. Legacy identifiers

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

# 1
Identifier600968049
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer

VIII. Authorized Official

Name: AMY HECHT
Title or Position: OWNER, CLINICAL DIRECTOR
Credential: LMHC, NCC, CCTP
Phone: 712-252-7170