Basic Information
| Provider Information | |||||||||
| NPI: | 1831164847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCKINNEY | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | FAYE | ||||||||
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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: | 145 W GREEN MEADOWS DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | GREENFIELD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461404002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174621481 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 08/18/2009 | ||||||||
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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 | 1041C0700X | 34002939A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 100270530 | 05 | IN | MEDICAID |