Provider Demographics
NPI:1568993269
Name:AMOS, TED (MDIV LMFT CSAYC)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:
Last Name:AMOS
Suffix:
Gender:M
Credentials:MDIV LMFT CSAYC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4319 E 56TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-5776
Mailing Address - Country:US
Mailing Address - Phone:317-775-7976
Mailing Address - Fax:
Practice Address - Street 1:5638 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241
Practice Address - Country:US
Practice Address - Phone:888-714-1927
Practice Address - Fax:317-247-8935
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001925106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist