Basic Information
| Provider Information | |||||||||
| NPI: | 1316356504 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHERN INDIANA THERAPIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4953 W CONCORD DR | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463507241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192290109 | ||||||||
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| Practice Location | |||||||||
| Address1: | 804 MONROE ST | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463503511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2192290109 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2014 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | WEBER | ||||||||
| AuthorizedOfficialFirstName: | VALERIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2192290109 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.