MEDICARE: SIMPLY DIVINE

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	103TC0700X	Clinical Psychologist	8700133A	IN

General Provider Information

NPI Number	:	1194172593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMPLY DIVINE

Provider Business Mailing Address
First Line	:	141 N SHORTRIDGE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-8906
Country	:	US
Telephone Number	:	317-263-1675
Fax Number	:

Provider Business Practice Location Address
First Line	:	141 N SHORTRIDGE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-8906
Country	:	US
Telephone Number	:	317-263-1675
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MICHAEL JAMES
Credential	:	LCAC
Telephone Number	:	317-263-1675

Provider Enumeration Date	:	05/16/2016
Last Update Date	:	07/15/2016

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