=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356845424
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONITA L HALE LICENSED SOCIAL WORK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2018
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2840 N HIGH SCHOOL RD STE 100
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46224-4724
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-986-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5760 ROSEMONT DR
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-5028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 131-743-9779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 33008644A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------