Provider Demographics
NPI:1538672365
Name:ENRICHING LIVES ORGANIZATION
Entity Type:Organization
Organization Name:ENRICHING LIVES ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-956-7529
Mailing Address - Street 1:4325 BLACK OAK DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-3109
Mailing Address - Country:US
Mailing Address - Phone:404-956-7529
Mailing Address - Fax:
Practice Address - Street 1:1775 N SHERMAN DR STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4493
Practice Address - Country:US
Practice Address - Phone:404-956-7529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YP2500X
IN87001214A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND6703519Medicaid