Provider Demographics
NPI:1750885505
Name:HART, BRANNON WALSMITH (HSPP)
Entity type:Individual
Prefix:
First Name:BRANNON
Middle Name:WALSMITH
Last Name:HART
Suffix:
Gender:M
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 N MITTHOEFFER RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2425
Mailing Address - Country:US
Mailing Address - Phone:317-934-0800
Mailing Address - Fax:317-355-6150
Practice Address - Street 1:5317 E 16TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4897
Practice Address - Country:US
Practice Address - Phone:317-355-3700
Practice Address - Fax:317-355-7793
Is Sole Proprietor?:No
Enumeration Date:2018-03-19
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043107A103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service