Healthcare Provider Details

I. General information

NPI: 1780594739
Provider Name (Legal Business Name): IMPACT & REBUILD WELLNESS & BEHAVIORAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2026
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10928 SPRING GREEN DR
INDIANAPOLIS IN
46229-3536
US

IV. Provider business mailing address

10928 SPRING GREEN DR
INDIANAPOLIS IN
46229-3536
US

V. Phone/Fax

Practice location:
  • Phone: 317-397-5845
  • Fax:
Mailing address:
  • Phone: 317-397-5845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND EDWARD FISHER SR.
Title or Position: FOUNDER/CEO
Credential:
Phone: 317-397-5845