Healthcare Provider Details

I. General information

NPI: 1285347427
Provider Name (Legal Business Name): TALISHA MARIE ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2023
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 CARROLLTON AVE
INDIANAPOLIS IN
46205-3542
US

IV. Provider business mailing address

3640 CARROLLTON AVE
INDIANAPOLIS IN
46205-3542
US

V. Phone/Fax

Practice location:
  • Phone: 317-599-2128
  • Fax:
Mailing address:
  • Phone: 317-599-2128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: