Provider Demographics
NPI:1366422388
Name:DETTNER, MICHAEL E (MS, LMHC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:DETTNER
Suffix:
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N PENNSYLVANIA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-4453
Mailing Address - Country:US
Mailing Address - Phone:317-968-0409
Mailing Address - Fax:317-968-0402
Practice Address - Street 1:1300 N PENNSYLVANIA ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4453
Practice Address - Country:US
Practice Address - Phone:317-968-0409
Practice Address - Fax:317-968-0402
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001119A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health