Healthcare Provider Details

I. General information

NPI: 1679458392
Provider Name (Legal Business Name): LAURA MARIA MITCHEL EDS, NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E WALNUT ST
INDIANAPOLIS IN
46204-1312
US

IV. Provider business mailing address

436 E PINE RIDGE DR
WESTFIELD IN
46074-9031
US

V. Phone/Fax

Practice location:
  • Phone: 317-226-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number000037179
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: