MEDICARE: JOURNEY THERAPY AT THE BARN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC2277	SD

General Provider Information

NPI Number	:	1093221335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOURNEY THERAPY AT THE BARN, LLC

Provider Business Mailing Address
First Line	:	1500 S SYCAMORE AVE STE 200
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-3711
Country	:	US
Telephone Number	:	605-838-8545
Fax Number	:	605-271-4155

Provider Business Practice Location Address
First Line	:	1500 S SYCAMORE AVE STE 200
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-3711
Country	:	US
Telephone Number	:	605-838-8545
Fax Number	:	605-271-4155

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	AMY M ROTH
Credential	:	MS, LPCMH, NCC
Telephone Number	:	605-838-8545

Provider Enumeration Date	:	12/22/2017
Last Update Date	:	12/22/2017

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