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General NPI Number Information
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NPI Number | 1407072762
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Entity Type | Organization
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Legal Business Name | LDS FAMILY SERVICES
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 09/14/2009
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Provider Practice Location Address
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Address Line | 550 CONGRESSIONAL BLVD SUITE 125
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City | CARMEL
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State | IN
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Zip | 46032-5609
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Country | US
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Telephone | 317-872-1749
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Fax | 317-872-1756
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Provider Business Mailing Address
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Address Line | 550 CONGRESSIONAL BLVD SUITE 125
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City | CARMEL
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State | IN
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Zip | 46032-5609
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Country | US
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Telephone | 317-872-1749
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Fax | 317-872-1756
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Authorized Official
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Title or Position | COUNSELING SUPERVISOR
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Name | MR. MATTHEW J WILSON
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Credential | LCSW
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Telephone | 317-522-0224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 169096933
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License Number State | IN
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