Provider Demographics
NPI:1265130587
Name:CHILDREN OF PROMISE MENTORING PROGRAM
Entity type:Organization
Organization Name:CHILDREN OF PROMISE MENTORING PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR HEALTH COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PLEDGEJOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:319-529-1543
Mailing Address - Street 1:1143 LONGFELLOW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1720
Mailing Address - Country:US
Mailing Address - Phone:319-529-1543
Mailing Address - Fax:
Practice Address - Street 1:1030 5TH AVE SE STE 1200
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2428
Practice Address - Country:US
Practice Address - Phone:319-529-1543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty