Healthcare Provider Details

I. General information

NPI: 1093760951
Provider Name (Legal Business Name): HEDGEHOG PSYCHIATRIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8563 ZIONSVILLE RD
INDIANAPOLIS IN
46268-1511
US

IV. Provider business mailing address

8563 ZIONSVILLE RD
INDIANAPOLIS IN
46268-1511
US

V. Phone/Fax

Practice location:
  • Phone: 317-337-9967
  • Fax: 317-337-9968
Mailing address:
  • Phone: 317-337-9967
  • Fax: 317-337-9968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003324A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number71000401A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number70000131A
License Number StateIN

VIII. Authorized Official

Name: MRS. PENNI FUQUA
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 317-337-9967