Healthcare Provider Details

I. General information

NPI: 1629336714
Provider Name (Legal Business Name): DONNA CISCO LCSW, LCAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DONNA SHINE LCSW

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

898 E MAIN ST
GREENWOOD IN
46143-1407
US

IV. Provider business mailing address

898 E MAIN ST
GREENWOOD IN
46143-1407
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-1348
  • Fax: 317-883-5225
Mailing address:
  • Phone: 317-887-1348
  • Fax: 317-883-5225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34005537A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: