Provider Demographics
NPI:1982054524
Name:FORTITUDE MENTAL HEALTH SERVICES L.L.C
Entity type:Organization
Organization Name:FORTITUDE MENTAL HEALTH SERVICES L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RUDEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:712-522-1119
Mailing Address - Street 1:101 CENTRAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-3620
Mailing Address - Country:US
Mailing Address - Phone:712-522-1119
Mailing Address - Fax:712-587-9695
Practice Address - Street 1:101 CENTRAL AVE SW
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-3620
Practice Address - Country:US
Practice Address - Phone:712-522-1119
Practice Address - Fax:712-587-9695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001719101YM0800X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA13575944OtherCAQH
IA600849393Medicaid
IA1689924466OtherNPI