MEDICARE: UNIVERSAL BEHAVIORAL SERVICE

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000221075	OTHER	IN	ANTHEM

General Provider Information

NPI Number	:	1154346047
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSAL BEHAVIORAL SERVICE

Provider Business Mailing Address
First Line	:	3590 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-4425
Country	:	US
Telephone Number	:	317-684-0442
Fax Number	:	317-684-0679

Provider Business Practice Location Address
First Line	:	3590 N MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46208-4425
Country	:	US
Telephone Number	:	317-684-0442
Fax Number	:	317-684-0679

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MS. INDINAR BUFORD
Credential	:
Telephone Number	:	317-684-0442

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	08/22/2020

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