Provider Demographics
NPI:1508140898
Name:GEORGE JUNIOR REPUBLIC IN INDIANA
Entity Type:Organization
Organization Name:GEORGE JUNIOR REPUBLIC IN INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:R
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:812-722-3137
Mailing Address - Street 1:3925 S. GARTHWAITE RD
Mailing Address - Street 2:
Mailing Address - City:GAS CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46933
Mailing Address - Country:US
Mailing Address - Phone:812-722-3137
Mailing Address - Fax:812-372-9299
Practice Address - Street 1:3925 S. GARTHWAITE RD
Practice Address - Street 2:
Practice Address - City:GAS CITY
Practice Address - State:IN
Practice Address - Zip Code:46933
Practice Address - Country:US
Practice Address - Phone:812-722-3137
Practice Address - Fax:812-372-9299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 104100000X, 106H00000X
IN152783933253J00000X
IN54490098253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253J00000XAgenciesFoster Care Agency
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty