MEDICARE: IRIS M CRIDER-NASH PHD, HSPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	20040287A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	58387816	OTHER	IN	UBH
2	067516	OTHER	IN	VALUE OPTIONS

General Provider Information

NPI Number	:	1538103254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRIS M CRIDER-NASH PHD, HSPP

Provider Business Mailing Address
First Line	:	5218 S EAST ST
Second Line	:	SUITE E-4
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-1900
Country	:	US
Telephone Number	:	317-781-0447
Fax Number	:	317-781-0465

Provider Business Practice Location Address
First Line	:	5218 S EAST ST
Second Line	:	SUITE E-4
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-1900
Country	:	US
Telephone Number	:	317-781-0447
Fax Number	:	317-781-0465

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	07/08/2007

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