Provider Demographics
NPI:1396180659
Name:MICHIANA COUNSELING GROUP, LLC
Entity Type:Organization
Organization Name:MICHIANA COUNSELING GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LALA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:574-344-7941
Mailing Address - Street 1:56218 PARKWAY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-9326
Mailing Address - Country:US
Mailing Address - Phone:574-293-0005
Mailing Address - Fax:574-293-0019
Practice Address - Street 1:56218 PARKWAY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-9326
Practice Address - Country:US
Practice Address - Phone:574-293-0005
Practice Address - Fax:574-293-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003589A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty