MEDICARE: STACEY GROVES LMFT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	87000981A	IN
2	106H00000X	Marriage & Family Therapist	35001558	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000841160	OTHER	IN	ANTHEM BCBS

General Provider Information

NPI Number	:	1326096967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY GROVES LMFT

Provider Business Mailing Address
First Line	:	6626 E 75TH STREET
Second Line	:	SUITE 500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:	317-621-7561
Fax Number	:	317-355-6096

Provider Business Practice Location Address
First Line	:	7 E HENDRICKS ST
Second Line	:
City	:	SHELBYVILLE
State	:	IN
Zip	:	46176-2124
Country	:	US
Telephone Number	:	317-392-2564
Fax Number	:	317-392-9545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	03/11/2014

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