Healthcare Provider Details

I. General information

NPI: 1528570801
Provider Name (Legal Business Name): MILAN STUBBLEFIELD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 10/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12827 OLD GLORY DR
FISHERS IN
46037-7188
US

IV. Provider business mailing address

12827 OLD GLORY DR
FISHERS IN
46037-7188
US

V. Phone/Fax

Practice location:
  • Phone: 765-215-3476
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: