Basic Information
| Provider Information | |||||||||
| NPI: | 1184612137 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY & CHILDREN'S CENTER OF COUNSELING AND DEVELOPMENT SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 LINCOLNWAY EAST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466013220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742322255 | ||||||||
| FaxNumber: | 5742328968 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 LINCOLNWAY EAST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466013220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742322255 | ||||||||
| FaxNumber: | 5742328968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANCOCK | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5742322255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103T00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 200264420 | 05 | IN | MEDICAID | 236961000 | 01 | IN | MAGELLAN | OTHER | 000000184548 | 01 | IN | ANTHEM | OTHER |