Provider Demographics
NPI:1558927764
Name:MAPLE CITY COUNSELING CENTER
Entity Type:Organization
Organization Name:MAPLE CITY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DD
Authorized Official - Last Name:JODWAY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LCAC
Authorized Official - Phone:574-220-0220
Mailing Address - Street 1:209 TANGLEWOOD DR APT C
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1718
Mailing Address - Country:US
Mailing Address - Phone:574-220-0220
Mailing Address - Fax:574-975-7788
Practice Address - Street 1:209 TANGLEWOOD DR APT C
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1718
Practice Address - Country:US
Practice Address - Phone:574-220-0220
Practice Address - Fax:574-975-7788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN39001485AOtherLICENSED MENTAL HEALTH COUNSELOR
IN87000367AOtherLICENSED CLINICAL ADDICTION COUNSELOR