=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265211270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISE MIND COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 04/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3913 SHADOW POINTE LN
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-3752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-331-0668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 53833
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-331-0668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRINA RANSOM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-331-0668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------