Basic Information
| Provider Information | |||||||||
| NPI: | 1508292582 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRENTWOOD MEADOWS, LLC | ||||||||
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| OtherOrganizationName: | BRENTWOOD MEADOWS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4488 ROSLIN RD | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128587200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4488 ROSLIN RD | ||||||||
| Address2: | |||||||||
| City: | NEWBURGH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 476308590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128587200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 09/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | SALEE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LICENSE AND REGULATION | ||||||||
| AuthorizedOfficialTelephone: | 8125988989 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRENTWOOD MEADOWS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0808X | 71003322A | IN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 2084P0800X | 01043877A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.