Healthcare Provider Details

I. General information

NPI: 1740789635
Provider Name (Legal Business Name): JONNA MARIE CAPIO LMHC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 E HAGAN ST STE 307
BLOOMINGTON IN
47401-8649
US

IV. Provider business mailing address

4972 E HERITAGE WOODS RD
BLOOMINGTON IN
47401-9175
US

V. Phone/Fax

Practice location:
  • Phone: 812-331-7773
  • Fax:
Mailing address:
  • Phone: 812-331-7773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number39002467A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002467A
License Number StateIN

VIII. Authorized Official

Name: JONNA M CAPIO
Title or Position: TIN OWNER
Credential: LMHC
Phone: 812-331-7773