Healthcare Provider Details

I. General information

NPI: 1942752761
Provider Name (Legal Business Name): INDIANAPOLIS COUNSELOR INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 EAST 64TH STREET #216
INDIANAPOLIS IN
46220-6610
US

IV. Provider business mailing address

10014 NORTHWIND DR
INDIANAPOLIS IN
46256-9339
US

V. Phone/Fax

Practice location:
  • Phone: 317-408-8880
  • Fax:
Mailing address:
  • Phone: 317-408-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number39002124A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002124A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number39002124A
License Number StateIN

VIII. Authorized Official

Name: RICHARD JONES
Title or Position: PRESIDENT
Credential: MDIV, LMHC
Phone: 314-408-8880