Provider Demographics
NPI:1962218305
Name:HICKORY GROVE BEHAVIORAL SERVICES, LLC
Entity type:Organization
Organization Name:HICKORY GROVE BEHAVIORAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:II
Authorized Official - Credentials:LMHC
Authorized Official - Phone:574-265-4428
Mailing Address - Street 1:265 S FEDERAL HWY STE 429
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33441-4161
Mailing Address - Country:US
Mailing Address - Phone:574-265-4428
Mailing Address - Fax:
Practice Address - Street 1:101 W 18TH ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-6830
Practice Address - Country:US
Practice Address - Phone:574-265-4428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty