Healthcare Provider Details

I. General information

NPI: 1013366251
Provider Name (Legal Business Name): ROUNDTABLE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 SOUTH ST
LAFAYETTE IN
47901-1416
US

IV. Provider business mailing address

904 SOUTH ST
LAFAYETTE IN
47901-1416
US

V. Phone/Fax

Practice location:
  • Phone: 765-630-7222
  • Fax:
Mailing address:
  • Phone: 765-630-7222
  • Fax: 765-807-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RENEE M TILT
Title or Position: OWNER & REGISTERED DIETITIAN
Credential: RDN, CSP
Phone: 765-630-7222