Provider Demographics
NPI:1356671192
Name:SEQUEL TSI OF INDIANA, LLC
Entity type:Organization
Organization Name:SEQUEL TSI OF INDIANA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUPAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-419-8913
Mailing Address - Street 1:2426 S PARKER LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47138-8561
Mailing Address - Country:US
Mailing Address - Phone:812-889-3992
Mailing Address - Fax:812-889-3990
Practice Address - Street 1:2426 S PARKER LN
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:IN
Practice Address - Zip Code:47138-8561
Practice Address - Country:US
Practice Address - Phone:812-889-3992
Practice Address - Fax:812-889-3990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children