Basic Information
| Provider Information | |||||||||
| NPI: | 1508058165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAHN | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2011 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179412200 | ||||||||
| FaxNumber: | 3179412208 | ||||||||
| Practice Location | |||||||||
| Address1: | 2011 N MERIDIAN ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179412200 | ||||||||
| FaxNumber: | 3179412208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 09/08/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20042294A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200932690 | 05 | IN | MEDICAID |