Basic Information
Provider Information | |||||||||
NPI: | 1730492018 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INDIANA CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 N SENATE BLVD | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462021239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179622622 | ||||||||
FaxNumber: | 3179638252 | ||||||||
Practice Location | |||||||||
Address1: | 1701 N SENATE BLVD | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462021239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179622622 | ||||||||
FaxNumber: | 3179638252 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2010 | ||||||||
LastUpdateDate: | 07/15/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OLISE-AIKINS | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: | ANN | ||||||||
AuthorizedOfficialTitleorPosition: | ASSESSMENT SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3179622622 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X |   |   | Y |   | Hospital Units | Psychiatric Unit |   |
ID Information
ID | Type | State | Issuer | Description | 2000119790 | 05 | IN |   | MEDICAID |