Provider Demographics
NPI:1639646409
Name:COLLAGE THERAPEUTIC GROUP LLC
Entity Type:Organization
Organization Name:COLLAGE THERAPEUTIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MEADOWS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-722-0999
Mailing Address - Street 1:6325 GUILFORD AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1741
Mailing Address - Country:US
Mailing Address - Phone:317-722-0999
Mailing Address - Fax:
Practice Address - Street 1:6325 GUILFORD AVE STE 206
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1741
Practice Address - Country:US
Practice Address - Phone:317-722-0999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty