Healthcare Provider Details

I. General information

NPI: 1003444985
Provider Name (Legal Business Name): COURAGEOUS HEALING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2013 S ANTHONY BLVD
FORT WAYNE IN
46803-3609
US

IV. Provider business mailing address

PO BOX 10156
FORT WAYNE IN
46850-0156
US

V. Phone/Fax

Practice location:
  • Phone: 260-417-4801
  • Fax:
Mailing address:
  • Phone: 260-417-4801
  • 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 Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JANELL LANE
Title or Position: CO-FOUNDER
Credential: MA
Phone: 260-417-4801