Healthcare Provider Details

I. General information

NPI: 1003790205
Provider Name (Legal Business Name): CROSS CONNECTIONS OF TIPPECANOE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2025
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 MAIN ST STE 500
LAFAYETTE IN
47901-2830
US

IV. Provider business mailing address

839 MAIN ST STE 500
LAFAYETTE IN
47901-2830
US

V. Phone/Fax

Practice location:
  • Phone: 765-412-8512
  • Fax: 765-374-2752
Mailing address:
  • Phone: 765-412-8512
  • Fax: 765-374-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JEAN HINES
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 765-427-8019