Provider Demographics
NPI:1235568734
Name:SYCAMORE SPRINGS, LLC
Entity Type:Organization
Organization Name:SYCAMORE SPRINGS, LLC
Other - Org Name:SYCAMORE SPRINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF LICENSE AND REGULATION
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:SALEE
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:812-598-8989
Mailing Address - Street 1:833 PARK EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-0785
Mailing Address - Country:US
Mailing Address - Phone:765-743-4400
Mailing Address - Fax:765-743-4411
Practice Address - Street 1:833 PARK EAST BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-0785
Practice Address - Country:US
Practice Address - Phone:765-743-4400
Practice Address - Fax:765-743-4411
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SYCAMORE SPRINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044009A207Q00000X
IN02002841A207Q00000X
IN01044028B2084P0800X
IN28150957A363LA2200X
IN28119850A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01044009AOtherLICENSE NUMBER
IN02002841AOtherLICENSE NUMBER
IN28119850AOtherLICENSE NUMBER
IN28150957AOtherLICENSE NUMBER
IN01044028BOtherLICENSE NUMBER