Provider Demographics
NPI:1740795640
Name:1 IDENTITY COUNSELING, LLC
Entity Type:Organization
Organization Name:1 IDENTITY COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, LPC, LCPC
Authorized Official - Phone:812-902-8007
Mailing Address - Street 1:1501 J ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-3847
Mailing Address - Country:US
Mailing Address - Phone:812-902-8007
Mailing Address - Fax:
Practice Address - Street 1:1501 J ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3847
Practice Address - Country:US
Practice Address - Phone:812-902-8007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002692A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty