Provider Demographics
NPI:1407503238
Name:FOSTER PARK COUNSELING LLC
Entity Type:Organization
Organization Name:FOSTER PARK COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARSHALL JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHCA
Authorized Official - Phone:260-444-7200
Mailing Address - Street 1:1027 W RUDISILL BLVD STE 207
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-2160
Mailing Address - Country:US
Mailing Address - Phone:260-347-3280
Mailing Address - Fax:
Practice Address - Street 1:1027 W RUDISILL BLVD STE 207
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-2160
Practice Address - Country:US
Practice Address - Phone:260-444-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1811533128Medicaid