MEDICARE: DAN J RECORD

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	1041C0700X	Clinical Social Worker	34003910A	IN

General Provider Information

NPI Number	:	1447213442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAN J RECORD

Provider Business Mailing Address
First Line	:	8180 CLEARVISTA PKWY
Second Line	:	230
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-5629
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8404 SIEAR TER
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-7215
Country	:	US
Telephone Number	:	317-887-7050
Fax Number	:

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

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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Directions to “ DAN J RECORD ” Practice Location

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