Provider Demographics
NPI:1407979917
Name:JOANN R HISCOX
Entity type:Organization
Organization Name:JOANN R HISCOX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:HISCOX
Authorized Official - Suffix:
Authorized Official - Credentials:MS, NCC, LMHC
Authorized Official - Phone:765-428-8108
Mailing Address - Street 1:200 FERRY ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47901-1172
Mailing Address - Country:US
Mailing Address - Phone:765-428-8108
Mailing Address - Fax:765-429-7088
Practice Address - Street 1:200 FERRY ST
Practice Address - Street 2:SUITE K
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-1172
Practice Address - Country:US
Practice Address - Phone:765-428-8108
Practice Address - Fax:765-429-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000412A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200336200AMedicaid