Provider Demographics
NPI:1679858831
Name:HOPE HAVEN PSYCHOLOGICAL RESOURCE, LLC
Entity type:Organization
Organization Name:HOPE HAVEN PSYCHOLOGICAL RESOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HEATH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-241-4673
Mailing Address - Street 1:125 N SHORTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4908
Mailing Address - Country:US
Mailing Address - Phone:317-241-4673
Mailing Address - Fax:317-241-0201
Practice Address - Street 1:125 N SHORTRIDGE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4908
Practice Address - Country:US
Practice Address - Phone:317-241-4673
Practice Address - Fax:317-241-0201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042331A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200976490Medicaid
IN201059010BMedicaid