Provider Demographics
NPI:1801972203
Name:PERSONAL DEVELOPMENT ASSOCIATES
Entity type:Organization
Organization Name:PERSONAL DEVELOPMENT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:C.
Authorized Official - Middle Name:HERBERT
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:PH D, HSPP
Authorized Official - Phone:317-923-6093
Mailing Address - Street 1:3225 NORTH MERIDIAN STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4680
Mailing Address - Country:US
Mailing Address - Phone:317-923-6093
Mailing Address - Fax:317-927-9833
Practice Address - Street 1:3225 NORTH MERIDIAN STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4680
Practice Address - Country:US
Practice Address - Phone:317-923-6093
Practice Address - Fax:317-927-9833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040083A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100227230Medicaid