Provider Demographics
NPI:1417546581
Name:CROSSROADS THERAPY PRACTICE LLC
Entity Type:Organization
Organization Name:CROSSROADS THERAPY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERSHIP
Authorized Official - Prefix:
Authorized Official - First Name:MARANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:574-747-7429
Mailing Address - Street 1:23463 GREENWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-6140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21764 OMEGA CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-7809
Practice Address - Country:US
Practice Address - Phone:574-747-7429
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)