Provider Demographics
NPI:1710097696
Name:INDIANA STATE UNIVERSITY
Entity Type:Organization
Organization Name:INDIANA STATE UNIVERSITY
Other - Org Name:ISU PSYCHOLOGY CLINIC-FACULTY PRACTICE SVCS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPROCK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, HSPP
Authorized Official - Phone:812-237-3317
Mailing Address - Street 1:450 N 7TH ST
Mailing Address - Street 2:ROOT HALL
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47809-1928
Mailing Address - Country:US
Mailing Address - Phone:812-237-3317
Mailing Address - Fax:812-237-8595
Practice Address - Street 1:450 N 7TH ST
Practice Address - Street 2:ROOT HALL
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47809-1928
Practice Address - Country:US
Practice Address - Phone:812-237-3317
Practice Address - Fax:812-237-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN607910Medicare ID - Type UnspecifiedJEAN KRISTELLER, PH.D., H