Provider Demographics
NPI:1912157140
Name:THE PILGRIMAGE CENTER, INC
Entity Type:Organization
Organization Name:THE PILGRIMAGE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:BLANKENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:MSSW/LCSW
Authorized Official - Phone:317-575-9855
Mailing Address - Street 1:10210 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1022
Mailing Address - Country:US
Mailing Address - Phone:317-575-9855
Mailing Address - Fax:317-575-1709
Practice Address - Street 1:10210 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46290-1022
Practice Address - Country:US
Practice Address - Phone:317-575-9855
Practice Address - Fax:317-575-1709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001869A101YM0800X
IN34000813A1041C0700X
IN35000794A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty