Healthcare Provider Details

I. General information

NPI: 1659876126
Provider Name (Legal Business Name): GOOD-ELLIOTT COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 S 3RD ST
GOSHEN IN
46526-3709
US

IV. Provider business mailing address

313 S 3RD ST
GOSHEN IN
46526-3709
US

V. Phone/Fax

Practice location:
  • Phone: 574-535-0880
  • Fax: 574-535-0882
Mailing address:
  • Phone: 574-535-0880
  • Fax: 574-535-0882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number340004467A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number34004467A
License Number StateIN

VIII. Authorized Official

Name: PHILIP DAVID GOOD-ELLIOTT
Title or Position: OWNER
Credential: MSW, LCSW
Phone: 574-535-0880