Healthcare Provider Details

I. General information

NPI: 1114253218
Provider Name (Legal Business Name): FRESH START COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 W LINCOLNWAY
VALPARAISO IN
46385-0300
US

IV. Provider business mailing address

1552 W LINCOLNWAY
VALPARAISO IN
46385-0300
US

V. Phone/Fax

Practice location:
  • Phone: 219-548-9400
  • Fax: 219-548-9444
Mailing address:
  • Phone: 219-548-9400
  • Fax: 219-548-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1194-0-ASO
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1194-0-ASO
License Number StateIN

VIII. Authorized Official

Name: MRS. VEROINCA RAMOS-CLARK
Title or Position: DIRECTOR
Credential: MAC
Phone: 219-548-9400