Provider Demographics
NPI:1215262175
Name:HEAD, MARY E (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:HEAD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 WISHARD BLVD
Mailing Address - Street 2:PRIMARY CARE CLINIC
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2872
Mailing Address - Country:US
Mailing Address - Phone:317-630-8893
Mailing Address - Fax:317-692-2372
Practice Address - Street 1:1002 WISHARD BLVD
Practice Address - Street 2:WISHARD PEDIATRIC PRIMARY CARE CLINIC
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2872
Practice Address - Country:US
Practice Address - Phone:317-630-8893
Practice Address - Fax:317-692-2372
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005835A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical