Provider Demographics
NPI:1730492018
Name:INDIANA CLINIC
Entity Type:Organization
Organization Name:INDIANA CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSESSMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:OLISE-AIKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-962-2622
Mailing Address - Street 1:1701 N SENATE BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1239
Mailing Address - Country:US
Mailing Address - Phone:317-962-2622
Mailing Address - Fax:317-963-8252
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-2622
Practice Address - Fax:317-963-8252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-15
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2000119790Medicaid