Provider Demographics
NPI:1053743088
Name:IBARRA, SUMMER L (PHD)
Entity type:Individual
Prefix:DR
First Name:SUMMER
Middle Name:L
Last Name:IBARRA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10293 N MERIDIAN ST
Mailing Address - Street 2:STE 210
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1079
Mailing Address - Country:US
Mailing Address - Phone:317-581-2292
Mailing Address - Fax:317-581-2285
Practice Address - Street 1:5230 E STOP 11 RD STE 350
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6402
Practice Address - Country:US
Practice Address - Phone:317-783-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042730A103G00000X, 103TR0400X
IN99058381A103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000863597OtherANTHEM
IN000000863597OtherANTHEM