MEDICARE: I AM BOUNDLESS, INC.

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	323P00000X	Psychiatric Residential Treatment Facility

General Provider Information

NPI Number	:	1205714599
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	I AM BOUNDLESS, INC.

Provider Business Mailing Address
First Line	:	445 E DUBLIN GRANVILLE RD STE H
Second Line	:
City	:	WORTHINGTON
State	:	OH
Zip	:	43085-3192
Country	:	US
Telephone Number	:	614-844-3800
Fax Number	:	614-515-5779

Provider Business Practice Location Address
First Line	:	MCDOWELL PRTF 2
Second Line	:	4218-4228 MCDOWELL ROAD
City	:	GROVE CITY
State	:	OH
Zip	:	43123
Country	:	US
Telephone Number	:	614-844-3800
Fax Number	:	614-515-5779

Authorized Official
Title or Position	:	CONTRACTING & CREDENTIALING MANAGER
Name	:	LAURIE B HICKMAN
Credential	:
Telephone Number	:	614-844-3800

Provider Enumeration Date	:	08/25/2025
Last Update Date	:	08/25/2025

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