Provider Demographics
NPI:1295853992
Name:PSYCHOLOGICAL LABORATORIES OF INDIANAPOLIS, PC
Entity Type:Organization
Organization Name:PSYCHOLOGICAL LABORATORIES OF INDIANAPOLIS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOEHLE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, HSPP
Authorized Official - Phone:317-925-1818
Mailing Address - Street 1:2625 N MERIDIAN ST
Mailing Address - Street 2:SUITE 18
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:NE
Mailing Address - Zip Code:46208
Mailing Address - Country:US
Mailing Address - Phone:317-925-1818
Mailing Address - Fax:317-924-6582
Practice Address - Street 1:2625 N MERIDIAN ST
Practice Address - Street 2:SUITE 18
Practice Address - City:INDIANAPOLIS
Practice Address - State:NE
Practice Address - Zip Code:46208
Practice Address - Country:US
Practice Address - Phone:317-925-1818
Practice Address - Fax:317-924-6582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN167500Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER