MEDICARE: CONNECTED IN COMMUNITY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1922605864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTED IN COMMUNITY, LLC

Provider Business Mailing Address
First Line	:	5625 N GERMAN CHURCH RD STE 105
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46235-8513
Country	:	US
Telephone Number	:	317-207-0380
Fax Number	:

Provider Business Practice Location Address
First Line	:	5625 N GERMAN CHURCH RD STE 105
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46235-8513
Country	:	US
Telephone Number	:	317-207-0380
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLA JOYCE CANNON YEARWOOD
Credential	:	LSW
Telephone Number	:	317-402-1604

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/05/2020

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