Provider Demographics
NPI:1679390132
Name:COLE, KARISA (EDS)
Entity type:Individual
Prefix:
First Name:KARISA
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 GUILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-1922
Mailing Address - Country:US
Mailing Address - Phone:313-300-9935
Mailing Address - Fax:
Practice Address - Street 1:4330 GUILFORD AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1922
Practice Address - Country:US
Practice Address - Phone:313-300-9935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10292699103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool