Provider Demographics
NPI:1710153010
Name:INDIANAPOLIS COUNSELING CENTER INC
Entity Type:Organization
Organization Name:INDIANAPOLIS COUNSELING CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:SR
Authorized Official - Credentials:MS CADAC II
Authorized Official - Phone:317-549-0333
Mailing Address - Street 1:724 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1116
Mailing Address - Country:US
Mailing Address - Phone:317-549-0333
Mailing Address - Fax:317-549-6933
Practice Address - Street 1:724 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1116
Practice Address - Country:US
Practice Address - Phone:317-549-0333
Practice Address - Fax:317-549-6933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000099A101Y00000X
101Y00000X
IN35001499A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty