Provider Demographics
NPI:1790922078
Name:MIDWEST PSYCHOLOGICAL CENTER, INC.
Entity Type:Organization
Organization Name:MIDWEST PSYCHOLOGICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELVY
Authorized Official - Middle Name:HAYWOOD
Authorized Official - Last Name:KEGLAR
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-923-3930
Mailing Address - Street 1:525 E 38TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2744
Mailing Address - Country:US
Mailing Address - Phone:317-923-3930
Mailing Address - Fax:317-923-2441
Practice Address - Street 1:525 E 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-2744
Practice Address - Country:US
Practice Address - Phone:317-923-3930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040520A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000183364OtherANTHEM
IN200020330AMedicaid
IN200020330AMedicaid