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Addiction Substance Use Disorder

Goshen, Indiana

Provider NPI: 1912949413

Provider Information:
Gender: M
Sole Proprietor

Practice Location:
Tel: 574-220-0220  Fax: 574-975-7788

Business Mailing Address:
Tel: 574-220-0220  Fax: 574-534-5778

Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
N101YA0400XBehavioral Health & Social Service Providers
Addiction (Substance Use Disorder)
Y101YM0800XBehavioral Health & Social Service Providers

Other Provider Identifiers:

Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin


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