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General NPI Number Information
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NPI Number | 1396818936
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Entity Type | Organization
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Legal Business Name | FAMILY TIES, INC.
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 700 GRACE ST
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51503-4974
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Country | US
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Telephone | 712-396-0290
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Fax | 712-396-0291
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Provider Business Mailing Address
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Address Line | 700 GRACE ST
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City | COUNCIL BLUFFS
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State | IA
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Zip | 51503-4974
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Country | US
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Telephone | 712-396-0290
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Fax | 712-396-0291
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. GARY D MAHONEY
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Credential | LMSW
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Telephone | 712-396-0290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 05908
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License Number State | IA
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