Provider Demographics
NPI:1528823697
Name:INDIANA TELEPSYCH NP, LLC
Entity type:Organization
Organization Name:INDIANA TELEPSYCH NP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:812-599-4138
Mailing Address - Street 1:1246 E MARIGOLD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8983
Mailing Address - Country:US
Mailing Address - Phone:812-599-4138
Mailing Address - Fax:
Practice Address - Street 1:1246 E MARIGOLD DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8983
Practice Address - Country:US
Practice Address - Phone:812-599-4138
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health