Healthcare Provider Details

I. General information

NPI: 1912632621
Provider Name (Legal Business Name): ROUNDTABLE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 ROME DR STE B
LAFAYETTE IN
47905-4490
US

IV. Provider business mailing address

3741 ROME DR STE B
LAFAYETTE IN
47905-4490
US

V. Phone/Fax

Practice location:
  • Phone: 765-490-4808
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: RENEE TILT
Title or Position: PRACTICE MANAGER
Credential:
Phone: 765-490-4808