MEDICARE: MERIDIAN YOUTH PSYCHIATRIC CENTER PC

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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1801918065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MERIDIAN YOUTH PSYCHIATRIC CENTER PC

Provider Business Mailing Address
First Line	:	210 E 91ST ST
Second Line	:	SUITE C
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1569
Country	:	US
Telephone Number	:	317-844-0055
Fax Number	:	317-571-5040

Provider Business Practice Location Address
First Line	:	210 E 91ST ST
Second Line	:	SUITE C
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1569
Country	:	US
Telephone Number	:	317-844-0055
Fax Number	:	317-571-5040

Authorized Official
Title or Position	:	CORPORATE SECRETARY TREASURER
Name	:	MIMI BRITTINGHAM
Credential	:	RN APN LMHC
Telephone Number	:	317-844-0055

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	10/09/2007

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