Healthcare Provider Details

I. General information

NPI: 1619804309
Provider Name (Legal Business Name): CARLY BACSO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3106 N CANTERBURY CT
BLOOMINGTON IN
47404-1500
US

IV. Provider business mailing address

8646 GUION RD
INDIANAPOLIS IN
46268-3011
US

V. Phone/Fax

Practice location:
  • Phone: 855-463-6887
  • Fax: 317-334-7336
Mailing address:
  • Phone: 317-334-7331
  • Fax: 317-334-7336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-534238
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: