Provider Demographics
NPI:1184906778
Name:INDIANA MENTOR
Entity type:Organization
Organization Name:INDIANA MENTOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:YNESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DOO
Authorized Official - Phone:317-581-2380
Mailing Address - Street 1:8925 N. MERIDIAN
Mailing Address - Street 2:#250
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-208-7720
Mailing Address - Fax:317-581-2387
Practice Address - Street 1:8925 N. MERIDIAN STREET
Practice Address - Street 2:#250
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-208-7720
Practice Address - Fax:317-581-2387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency