Healthcare Provider Details

I. General information

NPI: 1780171595
Provider Name (Legal Business Name): MATHEW TYLER GRIGGS LMHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 12/15/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL DR, CARMEL, IN 46032 SUITE D
CARMEL IN
46032
US

IV. Provider business mailing address

200 MEDICAL DR, CARMEL, IN 46032 SUITE D
CARMEL IN
46032
US

V. Phone/Fax

Practice location:
  • Phone: 317-674-3160
  • Fax:
Mailing address:
  • Phone: 176-743-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number88001271A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: