Healthcare Provider Details

I. General information

NPI: 1396180659
Provider Name (Legal Business Name): MICHIANA COUNSELING GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56218 PARKWAY AVE SUITE B
ELKHART IN
46516-9326
US

IV. Provider business mailing address

56218 PARKWAY AVE SUITE B
ELKHART IN
46516-9326
US

V. Phone/Fax

Practice location:
  • Phone: 574-293-0005
  • Fax: 574-293-0019
Mailing address:
  • Phone: 574-293-0005
  • Fax: 574-293-0019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003589A
License Number StateIN

VIII. Authorized Official

Name: JESSICA L. LALA
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 574-344-7941