Healthcare Provider Details

I. General information

NPI: 1508600719
Provider Name (Legal Business Name): ISAAC MICHAEL LLAMAS TEMPORARY LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5638 PROFESSIONAL CIR
INDIANAPOLIS IN
46241-5042
US

IV. Provider business mailing address

10628 PATOKA RD
INDIANAPOLIS IN
46239-9272
US

V. Phone/Fax

Practice location:
  • Phone: 888-714-1927
  • Fax:
Mailing address:
  • Phone: 317-315-6827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number99125591A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number99125591A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: