Healthcare Provider Details

I. General information

NPI: 1902710916
Provider Name (Legal Business Name): MIKALE TELFAIR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6635 E 21ST ST STE 100
INDIANAPOLIS IN
46219-2252
US

IV. Provider business mailing address

9365 COUNSELORS ROW STE 200
INDIANAPOLIS IN
46240-6418
US

V. Phone/Fax

Practice location:
  • Phone: 317-608-2824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: