Basic Information
| Provider Information | |||||||||
| NPI: | 1043804750 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEMSWITHIN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 756 N MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463078210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197790509 | ||||||||
| FaxNumber: | 2197386714 | ||||||||
| Practice Location | |||||||||
| Address1: | 756 N MADISON ST | ||||||||
| Address2: | |||||||||
| City: | CROWN POINT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463078210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197790509 | ||||||||
| FaxNumber: | 2197386714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2021 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 2197691670 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 300046922 | 05 | IN | MEDICAID |