Healthcare Provider Details

I. General information

NPI: 1154905248
Provider Name (Legal Business Name): MAEGHAN GROVE ACIT 1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1759 HOGAN DR
KOKOMO IN
46902-5078
US

IV. Provider business mailing address

1759 HOGAN DR
KOKOMO IN
46902-5078
US

V. Phone/Fax

Practice location:
  • Phone: 765-480-9187
  • Fax:
Mailing address:
  • Phone: 765-480-9187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberT-5101
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: