MEDICARE: ROUNDTABLE WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker
3	133V00000X	Registered Dietitian
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center
5	261QM1300X	Multi-Specialty Clinic/Center
6	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1023739067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROUNDTABLE WELLNESS

Provider Business Mailing Address
First Line	:	904 SOUTH ST
Second Line	:
City	:	LAFAYETTE
State	:	IN
Zip	:	47901-1416
Country	:	US
Telephone Number	:	765-630-7222
Fax Number	:	765-630-7905

Provider Business Practice Location Address
First Line	:	90 EXECUTIVE DR STE C
Second Line	:
City	:	CARMEL
State	:	IN
Zip	:	46032-2612
Country	:	US
Telephone Number	:	765-630-7222
Fax Number	:	765-630-7905

Authorized Official
Title or Position	:	OWNER, CEO, CLINICAL DIRECTOR
Name	:	RENEE MICHELLE TILT
Credential	:
Telephone Number	:	765-630-7222

Provider Enumeration Date	:	09/08/2022
Last Update Date	:	09/08/2022

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Directions to “ROUNDTABLE WELLNESS ” Practice Location

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