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General NPI Number Information
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NPI Number | 1962218305
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Entity Type | Organization
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Legal Business Name | HICKORY GROVE BEHAVIORAL SERVICES, LLC
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Dates
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Enumeration Date | 12/10/2024
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 101 W 18TH ST
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City | LA PORTE
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State | IN
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Zip | 46350-6830
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Country | US
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Telephone | 574-265-4428
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Fax |
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Provider Business Mailing Address
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Address Line | 265 S FEDERAL HWY STE 429
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City | DEERFIELD BEACH
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State | FL
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Zip | 33441-4161
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Country | US
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Telephone | 574-265-4428
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROBERT DALE OWENS II
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Credential | LMHC
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Telephone | 574-265-4428
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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