MEDICARE: IMPACT LIFE DECISIONS, INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1053054601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPACT LIFE DECISIONS, INC

Provider Business Mailing Address
First Line	:	2901 N POST RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-1540
Country	:	US
Telephone Number	:	317-749-4801
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 N POST RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-1540
Country	:	US
Telephone Number	:	317-749-4801
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	CAMILLE SCOTT TOLLIVER
Credential	:	EDD
Telephone Number	:	317-296-0338

Provider Enumeration Date	:	04/20/2022
Last Update Date	:	04/20/2022

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