Healthcare Provider Details

I. General information

NPI: 1144156431
Provider Name (Legal Business Name): KEATON A EVANS-BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 ESKENAZI AVE
INDIANAPOLIS IN
46202-5187
US

IV. Provider business mailing address

930 S ADAMS ST APT 14
BLOOMINGTON IN
47403-2134
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-0000
  • Fax:
Mailing address:
  • Phone: 765-461-3384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39005390A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: