Healthcare Provider Details

I. General information

NPI: 1669912820
Provider Name (Legal Business Name): MR. ANDREW CHARLES VALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 SORBONNE PL APT B
INDIANAPOLIS IN
46268-1431
US

IV. Provider business mailing address

8820 SORBONNE PL APT B
INDIANAPOLIS IN
46268-1431
US

V. Phone/Fax

Practice location:
  • Phone: 631-335-7100
  • Fax:
Mailing address:
  • Phone: 631-335-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071022663
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: