Provider Demographics
NPI:1518401868
Name:DAVIS MINTUN PROFESSIONAL SERVICES INC
Entity Type:Organization
Organization Name:DAVIS MINTUN PROFESSIONAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GARTH
Authorized Official - Last Name:MINTUN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-578-2122
Mailing Address - Street 1:6801 LAKE PLAZA DR
Mailing Address - Street 2:STE A102
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4061
Mailing Address - Country:US
Mailing Address - Phone:317-578-2122
Mailing Address - Fax:317-578-3655
Practice Address - Street 1:6801 LAKE PLAZA DR
Practice Address - Street 2:STE A102
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4061
Practice Address - Country:US
Practice Address - Phone:317-578-2122
Practice Address - Fax:317-578-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-06
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001376A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1497794572OtherINDIVIDUAL NPI NUMBER FOR THOMAS GARTH MINTUN