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NPI Code Detail

MEDICARE: EARTHEART LLC

MEDICARE: EARTHEART 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
1101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1720444813
Entity Type Code : Organization
Provider Name (Legal Business Name) : EARTHEART LLC
Provider Business Mailing Address
First Line : 4307 S LEONARD SPRINGS RD
Second Line :
City : BLOOMINGTON
State : IN
Zip : 47403-4078
Country : US
Telephone Number : 812-345-2176
Fax Number : 206-984-2440
Provider Business Practice Location Address
First Line : 4307 S LEONARD SPRINGS RD
Second Line :
City : BLOOMINGTON
State : IN
Zip : 47403-4078
Country : US
Telephone Number : 812-345-2176
Fax Number : 206-984-2440
Authorized Official
Title or Position : TIN OWNER
Name : BRET EARTHEART
Credential : LCSW
Telephone Number : 812-345-2176
Provider Enumeration Date : 01/06/2016
Last Update Date : 11/29/2018

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Directions to “EARTHEART LLC ” Practice Location

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