Healthcare Provider Details

I. General information

NPI: 1922199165
Provider Name (Legal Business Name): FAMILY COUNSELING CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 E US HIGHWAY 36
AVON IN
46123-7968
US

IV. Provider business mailing address

7125 E US HIGHWAY 36
AVON IN
46123-7968
US

V. Phone/Fax

Practice location:
  • Phone: 317-272-2190
  • Fax: 317-272-2199
Mailing address:
  • Phone: 317-272-2190
  • Fax: 317-272-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateIN

VIII. Authorized Official

Name: MS. JANETTE E BELUE-WILSON
Title or Position: CLINIC DIRECTOR
Credential: LCSW
Phone: 317-272-2190