Provider Demographics
NPI:1851906176
Name:BLUE, LARRY JOE (LAC, CHW, MATS, MTH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JOE
Last Name:BLUE
Suffix:
Gender:M
Credentials:LAC, CHW, MATS, MTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 CLEARVISTA PKWY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1400
Mailing Address - Country:US
Mailing Address - Phone:317-623-3007
Mailing Address - Fax:317-671-7189
Practice Address - Street 1:8202 CLEARVISTA PKWY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1400
Practice Address - Country:US
Practice Address - Phone:317-623-3007
Practice Address - Fax:317-671-7189
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86000347A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN32-0548053Other86000347A