Provider Demographics
NPI:1407980170
Name:INDIANA MENTOR
Entity Type:Organization
Organization Name:INDIANA MENTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-388-5150
Mailing Address - Street 1:9000 KEYSTONE CROSSING STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-2148
Mailing Address - Country:US
Mailing Address - Phone:317-208-7739
Mailing Address - Fax:617-790-4271
Practice Address - Street 1:9000 KEYSTONE XING STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-2148
Practice Address - Country:US
Practice Address - Phone:317-581-2380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2023-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN200193830320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200193830OtherPROVIDER NUMBER
IN300033125OtherPROVIDER NUMBER