Healthcare Provider Details

I. General information

NPI: 1629799184
Provider Name (Legal Business Name): INDY SUPERB ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2022
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 EMERSON WAY STE 404
INDIANAPOLIS IN
46226-1467
US

IV. Provider business mailing address

4164 N BUTLER AVE
INDIANAPOLIS IN
46226-4628
US

V. Phone/Fax

Practice location:
  • Phone: 317-941-7474
  • Fax: 317-941-7377
Mailing address:
  • Phone: 317-722-9334
  • Fax: 317-941-7377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: JASMINE SANDERS
Title or Position: CEO
Credential:
Phone: 317-722-9334