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General NPI Number Information
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NPI Number | 1417057662
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Entity Type | Individual
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Provider Name | ELIZABETH BUTLER VANTASSEL PH.D.
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Gender | Female
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 04/27/2016
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Provider Practice Location Address
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Address Line | 10293 N MERIDIAN ST STE 180
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City | INDIANAPOLIS
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State | IN
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Zip | 46290-1073
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Country | US
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Telephone | 317-503-7548
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Fax | 317-853-1314
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Provider Business Mailing Address
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Address Line | 10293 N MERIDIAN ST STE 180
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City | INDIANAPOLIS
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State | IN
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Zip | 46290-1073
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Country | US
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Telephone | 317-573-0748
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Fax | 317-853-1314
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20010401A
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License Number State | IN
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