MEDICARE: CONNIE'S CLUBHOUSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251C00000X	Developmentally Disabled Services Day Training Agency
2	1041C0700X	Clinical Social Worker
3	251S00000X	Community/Behavioral Health Agency
4	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
5	253Z00000X	In Home Supportive Care Agency
6	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
7	261Q00000X	Clinic/Center
8	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
9	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1396634580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNIE'S CLUBHOUSE

Provider Business Mailing Address
First Line	:	5142 MADISON AVE STE 7
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-4248
Country	:	US
Telephone Number	:	435-621-4153
Fax Number	:

Provider Business Practice Location Address
First Line	:	5142 MADISON AVE STE 7
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-4248
Country	:	US
Telephone Number	:	435-621-4153
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TAYLOR HINES MIRANDA
Credential	:
Telephone Number	:	435-621-4153

Provider Enumeration Date	:	07/01/2025
Last Update Date	:	03/19/2026

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Directions to “CONNIE'S CLUBHOUSE ” Practice Location

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