Healthcare Provider Details

I. General information

NPI: 1093320905
Provider Name (Legal Business Name): MARK ALAN HUTSLAR MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6635 E 21ST ST STE 100
INDIANAPOLIS IN
46219-2252
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 317-608-2824
  • Fax: 317-520-8200
Mailing address:
  • Phone: 855-324-0885
  • Fax: 317-520-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-59091
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: