Healthcare Provider Details

I. General information

NPI: 1639685571
Provider Name (Legal Business Name): MUSTARD SEED CENTER FOR GROWTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 E CARMEL DR STE 302
CARMEL IN
46032-3317
US

IV. Provider business mailing address

580 E CARMEL DR STE 302
CARMEL IN
46032-3317
US

V. Phone/Fax

Practice location:
  • Phone: 317-660-5737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KRISTIN KOUKA
Title or Position: OWNER
Credential:
Phone: 317-460-2384