=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497451751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING ROAD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2023
-----------------------------------------------------
Last Update Date | 03/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1403 TANAGER DR
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46580-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-377-9857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1403 TANAGER DR
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46580-2054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-377-9857
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANIEL CERVANTES
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 574-377-9857
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------