Healthcare Provider Details

I. General information

NPI: 1669057717
Provider Name (Legal Business Name): BEACON OF CHANGE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 E 98TH ST STE 110
CARMEL IN
46280-2942
US

IV. Provider business mailing address

3021 E 98TH ST STE 110
CARMEL IN
46280-2942
US

V. Phone/Fax

Practice location:
  • Phone: 317-530-3050
  • Fax:
Mailing address:
  • Phone: 317-530-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN RADER
Title or Position: OWNER
Credential: LMHC
Phone: 317-530-3050