Basic Information
| Provider Information | |||||||||
| NPI: | 1598860918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANGS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3173556096 | ||||||||
| Practice Location | |||||||||
| Address1: | 6950 HILLSDALE COURT | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217740 | ||||||||
| FaxNumber: | 3176621760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0807X | 70000157A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Child & Adolescent | 364SP0809X | 70000157A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 200981050 | 05 | IN | MEDICAID | 000000650514 | 01 | IN | ANTHEM | OTHER | 000000484985 | 01 | IN | ANTHEM | OTHER |