Provider Demographics
NPI:1508579616
Name:MANSFIELD, GRAE
Entity Type:Individual
Prefix:
First Name:GRAE
Middle Name:
Last Name:MANSFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:185-532-4088
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:1558 E BOULEVARD STE A
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-2587
Practice Address - Country:US
Practice Address - Phone:765-252-0530
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician