=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649325408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR CHILD AND FAMILY THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9247 N MERIDIAN ST SUITE 1A
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-815-6030
-----------------------------------------------------
Fax | 317-815-6031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9247 N MERIDIAN ST SUITE 104
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46260-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-815-6030
-----------------------------------------------------
Fax | 317-815-6031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST PRESIDENT
-----------------------------------------------------
Name | VALERIE J WEESNER
-----------------------------------------------------
Credential | PHD HSPP
-----------------------------------------------------
Telephone | 317-815-6030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 20040841A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------