Provider Demographics
NPI:1629359872
Name:THE LODGE COUNSELING & CONSULITING
Entity Type:Organization
Organization Name:THE LODGE COUNSELING & CONSULITING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-259-5134
Mailing Address - Street 1:705 DOUGLAS ST
Mailing Address - Street 2:SUITE # 208
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1048
Mailing Address - Country:US
Mailing Address - Phone:712-259-5134
Mailing Address - Fax:
Practice Address - Street 1:705 DOUGLAS ST
Practice Address - Street 2:SUITE # 208
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1048
Practice Address - Country:US
Practice Address - Phone:712-259-5134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty