Organization
INDIANA MENTOR
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARY PATRICIA RODENBERG-ROBERTS (VP & SR. ASST GENERAL COUNSEL)
(952) 836-2234
Entity
Organization
Contact information
Practice address
9000 KEYSTONE XING STE 200, INDIANAPOLIS, IN 46240-2148
(317) 581-2380
Mailing address
8777 PURDUE RD STE 360, INDIANAPOLIS, IN 46268-3121
(317) 208-7739
(617) 790-4271
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
200193830
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
200193830
PROVIDER NUMBER
IN
01
—
300033125
PROVIDER NUMBER
IN
Enumeration date
03/15/2007
Last updated
12/23/2024
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