Basic Information
Provider Information | |||||||||
NPI: | 1497233647 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEYOND THE CLOUDS COUNSELING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10811 CARDINAL CIR | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | IN | ||||||||
PostalCode: | 465637970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5749331201 | ||||||||
FaxNumber: | 5749687404 | ||||||||
Practice Location | |||||||||
Address1: | 505 COLONIAL CT | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH | ||||||||
State: | IN | ||||||||
PostalCode: | 465631860 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5749331201 | ||||||||
FaxNumber: | 5749687404 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/31/2018 | ||||||||
LastUpdateDate: | 07/31/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | TARA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/COUNSELOR | ||||||||
AuthorizedOfficialTelephone: | 5749331201 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34005729A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 1326225004 | 01 |   | INDIVIDUAL NPI | OTHER |