Healthcare Provider Details

I. General information

NPI: 1205434107
Provider Name (Legal Business Name): HOPE CHEST TIKKUN OLAM CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 10/13/2020
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 N GRANVILLE AVE STE C
MUNCIE IN
47303-2149
US

IV. Provider business mailing address

1715 N GRANVILLE AVE STE C
MUNCIE IN
47303-2149
US

V. Phone/Fax

Practice location:
  • Phone: 765-717-1403
  • Fax:
Mailing address:
  • Phone: 765-749-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. TERESA N LONG
Title or Position: THERAPIST
Credential: BSW. MSW, LSW
Phone: 765-717-1403