Provider Demographics
NPI:1871975771
Name:ALTMAN, MAURA L (PSYD)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:L
Last Name:ALTMAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:MAURA
Other - Middle Name:L
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 778912
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8912
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 5837
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-8167
Practice Address - Fax:317-944-9760
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042921103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300000104Medicaid
IN300000104Medicaid