Healthcare Provider Details

I. General information

NPI: 1952790354
Provider Name (Legal Business Name): PEACE A FAITH-BASED SUBSTANCE ABUSE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S EAST ST SUITE 205-C
INDIANAPOLIS IN
46227-2064
US

IV. Provider business mailing address

5401 S EAST ST SUITE 205-C
INDIANAPOLIS IN
46227-2064
US

V. Phone/Fax

Practice location:
  • Phone: 317-412-9737
  • Fax: 317-489-6089
Mailing address:
  • Phone: 317-412-9737
  • Fax: 317-489-6089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87000715A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROBIN DENISE CRUZ
Title or Position: EXECUTIVE DIRECTOR/OWNER
Credential: MSW, LCAC
Phone: 317-412-9737