Healthcare Provider Details

I. General information

NPI: 1225435639
Provider Name (Legal Business Name): IRVIN FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S 9TH ST SUITE 12
NOBLESVILLE IN
46060-2630
US

IV. Provider business mailing address

10 S 9TH ST SUITE 12
NOBLESVILLE IN
46060-2630
US

V. Phone/Fax

Practice location:
  • Phone: 317-332-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001851A
License Number StateIN

VIII. Authorized Official

Name: MRS. MELISSA IRVIN
Title or Position: OWNER
Credential: MA, LMFT
Phone: 317-332-6500