Basic Information
| Provider Information | |||||||||
| NPI: | 1750885505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HART | ||||||||
| FirstName: | BRANNON | ||||||||
| MiddleName: | WALSMITH | ||||||||
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| Credential: | HSPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1503 N MITTHOEFFER RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462292425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179340800 | ||||||||
| FaxNumber: | 3173556150 | ||||||||
| Practice Location | |||||||||
| Address1: | 5317 E 16TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462184897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173553700 | ||||||||
| FaxNumber: | 3173557793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TH0100X | 20043107A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Health Service |
No ID Information.