MEDICARE: BRANCHES OF LIFE FAMILY CONNECTIONS

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	251S00000X	Community/Behavioral Health Agency
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1366680902
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANCHES OF LIFE FAMILY CONNECTIONS

Provider Business Mailing Address
First Line	:	4954 E 56TH ST
Second Line	:	#10
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5773
Country	:	US
Telephone Number	:	317-449-0334
Fax Number	:	317-536-1070

Provider Business Practice Location Address
First Line	:	4954 E 56TH ST
Second Line	:	#10
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-5773
Country	:	US
Telephone Number	:	317-449-0334
Fax Number	:	317-536-1070

Authorized Official
Title or Position	:	PRESIDENT/THERAPIST
Name	:	MRS. SHANNON M DICKERSON
Credential	:	M.S
Telephone Number	:	317-446-4943

Provider Enumeration Date	:	02/03/2009
Last Update Date	:	01/14/2010

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Directions to “BRANCHES OF LIFE FAMILY CONNECTIONS ” Practice Location

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