Healthcare Provider Details

I. General information

NPI: 1093937476
Provider Name (Legal Business Name): BALL STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 W RIVERSIDE AVE HB 155
MUNCIE IN
47306-1022
US

IV. Provider business mailing address

1613 W RIVERSIDE AVE HB 155
MUNCIE IN
47306-1022
US

V. Phone/Fax

Practice location:
  • Phone: 765-285-5354
  • Fax: 765-285-5623
Mailing address:
  • Phone: 765-285-5354
  • Fax: 765-285-5623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002219A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002244A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23000144
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23002284A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22002106
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22000224A
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22001549
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22002004A
License Number StateIN
# 9
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22003906A
License Number StateIN
# 10
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22002254A
License Number StateIN
# 11
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22003456A
License Number StateIN
# 12
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22001560
License Number StateIN
# 13
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22001905A
License Number StateIN
# 14
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22002571
License Number StateIN
# 15
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number22001890A
License Number StateIN

VIII. Authorized Official

Name: BLAIR SCOTT MATTERN
Title or Position: DIR OF CLINICAL OPERATIONS
Credential:
Phone: 765-285-5354