Provider Demographics
NPI:1821323387
Name:FLACK, TINA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:FLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8820 S MERIDIAN ST
Practice Address - Street 2:STE 225
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-6056
Practice Address - Country:US
Practice Address - Phone:317-865-6922
Practice Address - Fax:317-865-6930
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003941A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN165490047Medicare PIN
IN264430350Medicare PIN