Healthcare Provider Details

I. General information

NPI: 1053688812
Provider Name (Legal Business Name): ALLIED BEHAVIORAL CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 GRANBY DR
CUMBERLAND IN
46229-2893
US

IV. Provider business mailing address

104 GRANBY DR
CUMBERLAND IN
46229-2893
US

V. Phone/Fax

Practice location:
  • Phone: 317-847-1645
  • Fax:
Mailing address:
  • Phone: 317-847-1645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001215A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000930A
License Number StateIN

VIII. Authorized Official

Name: KEVIN S. MINNICK
Title or Position: OWNER/PARTNER
Credential: MS CAS LMHC LCAC
Phone: 317-847-1645