Healthcare Provider Details

I. General information

NPI: 1245629096
Provider Name (Legal Business Name): POONAM ISHANPARA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2015
Last Update Date: 11/03/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6845 E US HIGHWAY 36 STE 500
AVON IN
46123-9781
US

IV. Provider business mailing address

6845 E US HIGHWAY 36 STE 500
AVON IN
46123-9781
US

V. Phone/Fax

Practice location:
  • Phone: 813-289-6597
  • Fax: 813-289-6592
Mailing address:
  • Phone: 317-742-1340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY9504
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number20042843A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042843A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20042843A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: