MEDICARE: DR. MICHAEL HINES PSYD, HSPP

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	103TH0100X	Health Service Psychologist	20042507A	IN
2	103TC0700X	Clinical Psychologist	20042507A	IN

General Provider Information

NPI Number	:	1679081806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL HINES PSYD, HSPP

Provider Business Mailing Address
First Line	:	5315 LAFAYETTE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-1618
Country	:	US
Telephone Number	:	317-974-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5315 LAFAYETTE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-1618
Country	:	US
Telephone Number	:	317-974-4000
Fax Number	:

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

Provider Enumeration Date	:	01/23/2018
Last Update Date	:	03/22/2022

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