Healthcare Provider Details

I. General information

NPI: 1073439790
Provider Name (Legal Business Name): SPECTRUM SOCIAL GROWTH AND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 TWIXWOOD LN
SOUTH BEND IN
46614-2471
US

IV. Provider business mailing address

2709 TWIXWOOD LN
SOUTH BEND IN
46614-2471
US

V. Phone/Fax

Practice location:
  • Phone: 269-501-2779
  • Fax:
Mailing address:
  • Phone: 269-501-2779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: NICOLE GAUTHIER
Title or Position: LCSW
Credential: LCSW, MPH
Phone: 269-501-2779