Healthcare Provider Details

I. General information

NPI: 1528823697
Provider Name (Legal Business Name): INDIANA TELEPSYCH NP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 02/19/2024
Certification Date: 02/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 E MARIGOLD DR
BLOOMINGTON IN
47401-8983
US

IV. Provider business mailing address

1246 E MARIGOLD DR
BLOOMINGTON IN
47401-8983
US

V. Phone/Fax

Practice location:
  • Phone: 812-599-4138
  • Fax:
Mailing address:
  • Phone: 812-599-4138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA KENT
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 812-599-4138