=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710559323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHSIDE PSYCHOTHERAPEUTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2021
-----------------------------------------------------
Last Update Date | 07/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 JOHN ST
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-850-3119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 321 JOHN ST
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46032-1214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-850-3119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PROVIDER
-----------------------------------------------------
Name | MS. ELIZABETH MCQUINN
-----------------------------------------------------
Credential | PMHCNS-BC
-----------------------------------------------------
Telephone | 317-850-3119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Clinical Nurse Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------