Provider Demographics
NPI:1174619654
Name:PROVIDENCE COUNSELING CENTER, INC.
Entity type:Organization
Organization Name:PROVIDENCE COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:C LAUDIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:260-418-6765
Mailing Address - Street 1:PO BOX 5622
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46895-5622
Mailing Address - Country:US
Mailing Address - Phone:260-418-6765
Mailing Address - Fax:260-416-0601
Practice Address - Street 1:10305 DAWSONS CREEK BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1914
Practice Address - Country:US
Practice Address - Phone:260-418-6765
Practice Address - Fax:260-416-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004602A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000259360Medicare UPIN