Provider Demographics
NPI:1407072762
Name:LDS FAMILY SERVICES
Entity type:Organization
Organization Name:LDS FAMILY SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COUNSELING SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:317-522-0224
Mailing Address - Street 1:550 CONGRESSIONAL BLVD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5609
Mailing Address - Country:US
Mailing Address - Phone:317-872-1749
Mailing Address - Fax:317-872-1756
Practice Address - Street 1:550 CONGRESSIONAL BLVD
Practice Address - Street 2:SUITE 125
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5609
Practice Address - Country:US
Practice Address - Phone:317-872-1749
Practice Address - Fax:317-872-1756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LDS FAMILY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN169096933261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)