| NPI | 1962002113 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER MORA Director Of Billing 219-850-4084 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 261QM0855X Clinic/Center, Adolescent and Children Mental Health | |
| Enumeration Date | 2020-10-27 |
| Last Update Date | 2020-10-27 |