1831353911 NPI number — LYDIA RUTH BANTON LMHC

Table of content: LYDIA RUTH BANTON LMHC (NPI 1831353911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831353911 NPI number — LYDIA RUTH BANTON LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANTON
Provider First Name:
LYDIA
Provider Middle Name:
RUTH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831353911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E 75TH STREET
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-621-7561
Provider Business Mailing Address Fax Number:
317-355-6096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5470 EAST 16TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46218-4861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-355-5394
Provider Business Practice Location Address Fax Number:
317-351-7580
Provider Enumeration Date:
07/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  39002262A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100270530 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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