Provider Demographics
NPI:1679182174
Name:SOUTHERN INDIANA THERAPEUTICS, LLC
Entity Type:Organization
Organization Name:SOUTHERN INDIANA THERAPEUTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:502-817-1385
Mailing Address - Street 1:2819 ENGLE RD
Mailing Address - Street 2:
Mailing Address - City:STARLIGHT
Mailing Address - State:IN
Mailing Address - Zip Code:47106-8423
Mailing Address - Country:US
Mailing Address - Phone:502-817-1385
Mailing Address - Fax:
Practice Address - Street 1:2819 ENGLE RD
Practice Address - Street 2:
Practice Address - City:STARLIGHT
Practice Address - State:IN
Practice Address - Zip Code:47106-8423
Practice Address - Country:US
Practice Address - Phone:502-817-1385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health