Healthcare Provider Details

I. General information

NPI: 1023760725
Provider Name (Legal Business Name): EARLY IMPACT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4243 STUBBINGTON LN
INDIANAPOLIS IN
46239-1597
US

IV. Provider business mailing address

4243 STUBBINGTON LN
INDIANAPOLIS IN
46239-1597
US

V. Phone/Fax

Practice location:
  • Phone: 317-319-7622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: RYAN HALL
Title or Position: OWNER
Credential:
Phone: 317-319-7622