Provider Demographics
NPI:1033505946
Name:EXTRA SPECIAL PARENTS OF INDIANA, LLC
Entity Type:Organization
Organization Name:EXTRA SPECIAL PARENTS OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:OOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:812-274-0228
Mailing Address - Street 1:402 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-3717
Mailing Address - Country:US
Mailing Address - Phone:812-274-0228
Mailing Address - Fax:812-274-0466
Practice Address - Street 1:402 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-3717
Practice Address - Country:US
Practice Address - Phone:812-274-0228
Practice Address - Fax:812-274-0466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN16890ASO251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health