=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437478864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERIC FOSTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2010
-----------------------------------------------------
Last Update Date | 05/25/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 WEST JEFFERSON ST.
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46563-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-936-3377
-----------------------------------------------------
Fax | 574-936-3910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 322 W JEFFERSON ST
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46563-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-936-3377
-----------------------------------------------------
Fax | 574-936-3910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ERIC WAYNE FOSTER
-----------------------------------------------------
Credential | MA, LMHC
-----------------------------------------------------
Telephone | 574-936-3377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 39000890A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------