Basic Information
| Provider Information | |||||||||
| NPI: | 1417553793 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RESTORE AND RECOVER COUNSELING LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14074 TRADE CENTER DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460384575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177757797 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14074 TRADE CENTER DR STE 220 | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460384575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177757797 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2020 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | LIEDTKE | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3177757797 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW,LCAC | ||||||||
| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.