Provider Demographics
NPI:1710559323
Name:NORTHSIDE PSYCHOTHERAPEUTICS
Entity Type:Organization
Organization Name:NORTHSIDE PSYCHOTHERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUINN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHCNS-BC
Authorized Official - Phone:317-850-3119
Mailing Address - Street 1:321 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1214
Mailing Address - Country:US
Mailing Address - Phone:317-850-3119
Mailing Address - Fax:
Practice Address - Street 1:321 JOHN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1214
Practice Address - Country:US
Practice Address - Phone:317-850-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Single Specialty