=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316990880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 FERRY ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-3047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-446-9898
-----------------------------------------------------
Fax | 765-446-9424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2201 FERRY ST
-----------------------------------------------------
City | LAFAYETTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47904-3047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-446-9898
-----------------------------------------------------
Fax | 765-446-9424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DENNIS WAYNE EDWARDS
-----------------------------------------------------
Credential | PHD, LMFT
-----------------------------------------------------
Telephone | 765-446-9898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 35001121A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------