Healthcare Provider Details

I. General information

NPI: 1336300359
Provider Name (Legal Business Name): VALLE VISTA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

898 E MAIN ST
GREENWOOD IN
46143-1407
US

IV. Provider business mailing address

898 E MAIN ST
GREENWOOD IN
46143-1407
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-1348
  • Fax: 317-885-9063
Mailing address:
  • Phone: 317-887-1348
  • Fax: 317-885-9063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3071PIP
License Number StateIN

VIII. Authorized Official

Name: MR. GLENN DAVID BELL JR.
Title or Position: CEO
Credential:
Phone: 317-887-1348