Basic Information
| Provider Information | |||||||||
| NPI: | 1225140965 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUTHERAN CHILD AND FAMILY SERVICES OF INDIANA/KENTUCKY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LCFS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1525 N RITTER AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173595467 | ||||||||
| FaxNumber: | 3173224095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 N RITTER AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462193026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173595467 | ||||||||
| FaxNumber: | 3173224095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3173595467 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 73545 49-900998 | IN | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 000000487150 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |