MEDICARE: MACNIFICENT MINDS, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1073497574
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACNIFICENT MINDS, LLC

Provider Business Mailing Address
First Line	:	4333 VILLAGE TRACE CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-6232
Country	:	US
Telephone Number	:	317-652-9627
Fax Number	:

Provider Business Practice Location Address
First Line	:	4333 VILLAGE TRACE CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-6232
Country	:	US
Telephone Number	:	317-652-9627
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ASHLEE MACK
Credential	:	NP
Telephone Number	:	317-652-9627

Provider Enumeration Date	:	08/05/2025
Last Update Date	:	08/05/2025

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