Healthcare Provider Details

I. General information

NPI: 1033890157
Provider Name (Legal Business Name): MICHAEL MAKSIMOVICH LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6314 RUCKER RD STE A
INDIANAPOLIS IN
46220-4800
US

IV. Provider business mailing address

6314 RUCKER RD STE A
INDIANAPOLIS IN
46220-4800
US

V. Phone/Fax

Practice location:
  • Phone: 317-250-4149
  • Fax: 317-465-9689
Mailing address:
  • Phone: 317-250-4149
  • Fax: 317-465-9689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL JOHN MAKSIMOVICH
Title or Position: OWNER/PRESIDENT
Credential: LCSW
Phone: 317-250-4149