MEDICARE: ATILGAB PSYCHOTHERAPY LLC

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)

General Provider Information

NPI Number	:	1326837717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATILGAB PSYCHOTHERAPY LLC

Provider Business Mailing Address
First Line	:	2346 S LYNHURST DR STE C201B
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46241-5104
Country	:	US
Telephone Number	:	317-507-1419
Fax Number	:

Provider Business Practice Location Address
First Line	:	2346 S LYNHURST DR STE C201B
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46241-5104
Country	:	US
Telephone Number	:	317-507-1419
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER
Name	:	GABRIEL OLUGBENGA ATILOLA
Credential	:
Telephone Number	:	317-507-1419

Provider Enumeration Date	:	05/02/2025
Last Update Date	:	05/02/2025

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