Provider Demographics
NPI:1508052317
Name:STOLKIN, SUE (LMFT)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:
Last Name:STOLKIN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7165 CLEARVISTA WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4621
Practice Address - Country:US
Practice Address - Phone:317-621-7561
Practice Address - Fax:317-355-6096
Is Sole Proprietor?:No
Enumeration Date:2007-09-15
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000756A101YM0800X
IN35001344A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN1031373OtherCIGNA
IN372491OtherMANAGED HEALTH NETWORK
IN372491OtherMANAGED HEALTH NETWORK
IN000000748964Medicare PIN