Basic Information
| Provider Information | |||||||||
| NPI: | 1093884827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HINES | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | KYLE | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8180 CLEARVISTA PARKWAY | ||||||||
| Address2: | SUITE 230 ATTN SHERRY MUELLER | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462564649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3176217470 | ||||||||
| Practice Location | |||||||||
| Address1: | 7165 CLEARVISTA PARKWAY | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462564621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176215100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 09/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34001994A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200042460A | 05 | IN | MEDICAID |