Provider Demographics
NPI:1366680902
Name:BRANCHES OF LIFE FAMILY CONNECTIONS
Entity Type:Organization
Organization Name:BRANCHES OF LIFE FAMILY CONNECTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:M
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:317-446-4943
Mailing Address - Street 1:4954 E 56TH ST
Mailing Address - Street 2:#10
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-5773
Mailing Address - Country:US
Mailing Address - Phone:317-449-0334
Mailing Address - Fax:317-536-1070
Practice Address - Street 1:4954 E 56TH ST
Practice Address - Street 2:#10
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-5773
Practice Address - Country:US
Practice Address - Phone:317-449-0334
Practice Address - Fax:317-536-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty