Basic Information
Provider Information | |||||||||
NPI: | 1356400576 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASPIRE INDIANA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BEHAVIORCORP | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9615 E 148TH ST | ||||||||
Address2: | SUITE 1 | ||||||||
City: | NOBLESVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 460604371 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175870500 | ||||||||
FaxNumber: | 3176740060 | ||||||||
Practice Location | |||||||||
Address1: | 9615 E 148TH ST | ||||||||
Address2: | SUITE 1 | ||||||||
City: | NOBLESVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 460604371 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175870500 | ||||||||
FaxNumber: | 3176740060 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CROCKETT | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 3175870517 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 100073590F | 05 | IN |   | MEDICAID |