Healthcare Provider Details

I. General information

NPI: 1114145182
Provider Name (Legal Business Name): MIDTOWN COMMUNITY MENTAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3171 N MERIDIAN ST
INDIANAPOLIS IN
46208-4784
US

IV. Provider business mailing address

3171 N MERIDIAN ST
INDIANAPOLIS IN
46208-4784
US

V. Phone/Fax

Practice location:
  • Phone: 317-941-5010
  • Fax:
Mailing address:
  • Phone: 317-941-5010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number34004950A
License Number StateIN

VIII. Authorized Official

Name: MS. DEBORAH WELLS
Title or Position: SUPERVISOR
Credential:
Phone: 317-941-5010