=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417546581
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSSROADS THERAPY PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2021
-----------------------------------------------------
Last Update Date | 01/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21764 OMEGA CT
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46528-7809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-747-7429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23463 GREENWOOD BLVD
-----------------------------------------------------
City | ELKHART
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46516-6140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNERSHIP
-----------------------------------------------------
Name | MARANDA HOUSER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 574-747-7429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------