Healthcare Provider Details

I. General information

NPI: 1083906531
Provider Name (Legal Business Name): FAMILY PRESERVATION COUNSELING & CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 N TACOMA AVE SUITE 201
INDIANAPOLIS IN
46220-3512
US

IV. Provider business mailing address

5555 N TACOMA AVE SUITE 201
INDIANAPOLIS IN
46220-3512
US

V. Phone/Fax

Practice location:
  • Phone: 317-259-7122
  • Fax: 317-259-7167
Mailing address:
  • Phone: 317-259-7122
  • Fax: 317-259-7167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34002010A
License Number StateIN

VIII. Authorized Official

Name: MRS. DEBRA DENIESE BUCKNER
Title or Position: OWNER, DIRECTOR
Credential: LCSW
Phone: 317-259-7122