Provider Demographics
NPI:1407291883
Name:BECOME FABULOUS
Entity Type:Organization
Organization Name:BECOME FABULOUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-840-8444
Mailing Address - Street 1:1534 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46404-2725
Mailing Address - Country:US
Mailing Address - Phone:219-882-4010
Mailing Address - Fax:219-882-0210
Practice Address - Street 1:1534 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46404-2725
Practice Address - Country:US
Practice Address - Phone:219-882-4010
Practice Address - Fax:219-882-0210
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 Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health