Healthcare Provider Details

I. General information

NPI: 1700513264
Provider Name (Legal Business Name): COWDEN MENTORING GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12510 BENT OAK LN
INDIANAPOLIS IN
46236-7378
US

IV. Provider business mailing address

5868 E 71ST ST
INDIANAPOLIS IN
46220-4075
US

V. Phone/Fax

Practice location:
  • Phone: 317-488-1417
  • Fax:
Mailing address:
  • Phone: 317-488-1417
  • 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. KERRY V. COWDEN SR.
Title or Position: BEHAVIORAL HEALTH PROVIDER
Credential:
Phone: 317-488-1417