Healthcare Provider Details

I. General information

NPI: 1265295588
Provider Name (Legal Business Name): ETHAN TRISTAN TINSLEY LMHC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 N MERIDIAN ST
INDIANAPOLIS IN
46208-5728
US

IV. Provider business mailing address

5638 PROFESSIONAL CIR
INDIANAPOLIS IN
46241-5042
US

V. Phone/Fax

Practice location:
  • Phone: 317-634-6341
  • Fax:
Mailing address:
  • Phone: 888-714-1927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39006125A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: