Healthcare Provider Details

I. General information

NPI: 1790111995
Provider Name (Legal Business Name): KATHERINE LITTLE KIVISTO PH.D., HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE CLAIRE LITTLE

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E HANNA AVE GOOD HALL 109
INDIANAPOLIS IN
46227-3630
US

IV. Provider business mailing address

1400 E HANNA AVE GOOD HALL 109
INDIANAPOLIS IN
46227-3630
US

V. Phone/Fax

Practice location:
  • Phone: 317-788-3790
  • Fax:
Mailing address:
  • Phone: 317-788-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20042671A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number20042671A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number20042671A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: