Provider Demographics
NPI:1689005118
Name:NORTHSIDE MENTAL HEALTH
Entity Type:Organization
Organization Name:NORTHSIDE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-819-8337
Mailing Address - Street 1:6507 FERGUSON ST
Mailing Address - Street 2:SUITE #102
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1294
Mailing Address - Country:US
Mailing Address - Phone:317-819-8337
Mailing Address - Fax:317-819-8332
Practice Address - Street 1:6507 FERGUSON ST
Practice Address - Street 2:SUITE #102
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1294
Practice Address - Country:US
Practice Address - Phone:317-819-8337
Practice Address - Fax:317-819-8332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006184A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty