Healthcare Provider Details

I. General information

NPI: 1255396750
Provider Name (Legal Business Name): EVELYN E JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 09/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7165 CLEARVISTA PARKWAY
INDIANAPOLIS IN
46256-4621
US

IV. Provider business mailing address

8180 CLEARVISTA PARKWAY SUITE 230 ATTN SHERRY MUELLER
INDIANAPOLIS IN
46256-4649
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003028A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35000525A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: