Healthcare Provider Details

I. General information

NPI: 1649037730
Provider Name (Legal Business Name): BLOSSOMING MINDS PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14074 TRADE CENTER DR STE 208
FISHERS IN
46038-4574
US

IV. Provider business mailing address

14074 TRADE CENTER DR STE 208
FISHERS IN
46038-4574
US

V. Phone/Fax

Practice location:
  • Phone: 317-967-4099
  • Fax:
Mailing address:
  • Phone: 317-967-4099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTINE MARIE LIEDTKE
Title or Position: OWNER
Credential: PSYD., HSPP
Phone: 317-967-4099