Healthcare Provider Details

I. General information

NPI: 1821323387
Provider Name (Legal Business Name): TINA MARIE FLACK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA MARIE WOOD LCSW

II. Dates (important events)

Enumeration Date: 10/16/2009
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 S MERIDIAN ST STE 225
INDIANAPOLIS IN
46217-6056
US

IV. Provider business mailing address

6626 E 75TH STREET STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-865-6922
  • Fax: 317-865-6930
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003941A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: