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General NPI Number Information
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NPI Number | 1528823697
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Entity Type | Organization
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Legal Business Name | INDIANA TELEPSYCH NP, LLC
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Dates
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Enumeration Date | 02/19/2024
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Last Update Date | 02/19/2024
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Provider Practice Location Address
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Address Line | 1246 E MARIGOLD DR
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City | BLOOMINGTON
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State | IN
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Zip | 47401-8983
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Country | US
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Telephone | 812-599-4138
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Fax |
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Provider Business Mailing Address
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Address Line | 1246 E MARIGOLD DR
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City | BLOOMINGTON
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State | IN
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Zip | 47401-8983
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Country | US
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Telephone | 812-599-4138
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. AMANDA KENT
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Credential | PMHNP-BC
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Telephone | 812-599-4138
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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