Healthcare Provider Details

I. General information

NPI: 1780480822
Provider Name (Legal Business Name): AQUARIAN MINISTRY LTD SPIRITUALIST CHURCH OF INTEGRATIVE HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 02/20/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GRACE CLINIC 620 8TH AVE
TERRE HAUTE IN
47804
US

IV. Provider business mailing address

858 N LASALLE ST
INDIANAPOLIS IN
46201-2556
US

V. Phone/Fax

Practice location:
  • Phone: 812-231-8350
  • Fax:
Mailing address:
  • Phone: 317-907-4198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TERESE A POLING
Title or Position: DOCTOR OF MEDICINE
Credential: MD
Phone: 317-907-4198