Healthcare Provider Details

I. General information

NPI: 1245999150
Provider Name (Legal Business Name): PHD MENTORING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2021
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8218 ST CLIFFORD CT
INDIANAPOLIS IN
46239-8996
US

IV. Provider business mailing address

8218 ST CLIFFORD CT
INDIANAPOLIS IN
46239-8996
US

V. Phone/Fax

Practice location:
  • Phone: 317-667-8409
  • Fax:
Mailing address:
  • Phone: 317-667-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. CLARENCE MARTIN JR.
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential:
Phone: 317-667-8409