Provider Demographics
NPI:1275043069
Name:RENAE CLARK-WEATHERLY
Entity Type:Organization
Organization Name:RENAE CLARK-WEATHERLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK-WEATHERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:317-222-9704
Mailing Address - Street 1:5126 GUION RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1725
Mailing Address - Country:US
Mailing Address - Phone:317-222-9704
Mailing Address - Fax:
Practice Address - Street 1:4126 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2613
Practice Address - Country:US
Practice Address - Phone:317-686-0931
Practice Address - Fax:866-406-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99064493A251B00000X
251B00000X
IN99074128A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health