Provider Demographics
NPI:1003538612
Name:COURAGEOUS AIM LLC
Entity Type:Organization
Organization Name:COURAGEOUS AIM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CAROTHERS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:563-505-0141
Mailing Address - Street 1:2805 EASTERN AVE STE D
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2074
Mailing Address - Country:US
Mailing Address - Phone:563-505-0141
Mailing Address - Fax:
Practice Address - Street 1:2805 EASTERN AVE STE D
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2074
Practice Address - Country:US
Practice Address - Phone:563-505-0141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074526Medicaid