MEDICARE: SUPPORTIVE SYSTEMS, LLC

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	34001241A	IN

General Provider Information

NPI Number	:	1871771493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE SYSTEMS, LLC

Provider Business Mailing Address
First Line	:	25 BEACHWAY DR
Second Line	:	SUITE C
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-8506
Country	:	US
Telephone Number	:	317-788-4111
Fax Number	:	317-788-7783

Provider Business Practice Location Address
First Line	:	25 BEACHWAY DR
Second Line	:	SUITE C
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46224-8506
Country	:	US
Telephone Number	:	317-788-4111
Fax Number	:	317-788-7783

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	PAMELA L. RUSTER
Credential	:	M.S.S.W.
Telephone Number	:	317-788-4111

Provider Enumeration Date	:	02/06/2008
Last Update Date	:	02/06/2008

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