Healthcare Provider Details

I. General information

NPI: 1700517257
Provider Name (Legal Business Name): KYLE WELLENDORF MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6291 CAMBRIDGE WAY STE 200
PLAINFIELD IN
46168-7944
US

IV. Provider business mailing address

202 MYERS RD
DANVILLE IN
46122-9702
US

V. Phone/Fax

Practice location:
  • Phone: 317-718-8436
  • Fax: 317-718-8438
Mailing address:
  • Phone: 317-718-8436
  • Fax: 317-718-8438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: