MEDICARE: DAVIS MINTUN PROFESSIONAL SERVICES INC

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	34001376A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1497794572	OTHER	IN	INDIVIDUAL NPI NUMBER FOR THOMAS GARTH MINTUN

General Provider Information

NPI Number	:	1518401868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIS MINTUN PROFESSIONAL SERVICES INC

Provider Business Mailing Address
First Line	:	6801 LAKE PLAZA DR
Second Line	:	STE A102
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4061
Country	:	US
Telephone Number	:	317-578-2122
Fax Number	:	317-578-3655

Provider Business Practice Location Address
First Line	:	6801 LAKE PLAZA DR
Second Line	:	STE A102
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4061
Country	:	US
Telephone Number	:	317-578-2122
Fax Number	:	317-578-3655

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. THOMAS GARTH MINTUN
Credential	:	LCSW
Telephone Number	:	317-578-2122

Provider Enumeration Date	:	12/06/2016
Last Update Date	:	12/06/2016

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