Provider Demographics
NPI:1093937476
Name:BALL STATE UNIVERSITY
Entity Type:Organization
Organization Name:BALL STATE UNIVERSITY
Other - Org Name:INTERPROFESSIONAL COMMUNITY CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MATTERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-285-5354
Mailing Address - Street 1:1613 W RIVERSIDE AVE HB 155
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47306-1022
Mailing Address - Country:US
Mailing Address - Phone:765-285-5354
Mailing Address - Fax:765-285-5623
Practice Address - Street 1:1613 W RIVERSIDE AVE HB 155
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47306-1022
Practice Address - Country:US
Practice Address - Phone:765-285-5354
Practice Address - Fax:765-285-5623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002219A231H00000X
IN23002244A231H00000X
IN23000144231H00000X
IN23002284A231H00000X
IN22002106235Z00000X
IN22000224A235Z00000X
IN22001549235Z00000X
IN22002004A235Z00000X
IN22003906A235Z00000X
IN22002254A235Z00000X
IN22003456A235Z00000X
IN22001560235Z00000X
IN22001905A235Z00000X
IN22002571235Z00000X
IN22001890A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty