Healthcare Provider Details

I. General information

NPI: 1821564774
Provider Name (Legal Business Name): ALYSSA KIANN RENNAKER LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3171 N MERIDIAN ST
INDIANAPOLIS IN
46208-4784
US

IV. Provider business mailing address

720 ESKENAZI AVE FIFTH THIRD BANK BLDG, 5TH FL
INDIANAPOLIS IN
46202-5166
US

V. Phone/Fax

Practice location:
  • Phone: 317-880-3036
  • Fax:
Mailing address:
  • Phone: 317-880-4121
  • Fax: 317-880-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39003370A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: