Healthcare Provider Details

I. General information

NPI: 1366269847
Provider Name (Legal Business Name): IRIS LAURE ONDOUA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10862 ZIMMERMAN LN
INDIANAPOLIS IN
46231-2001
US

IV. Provider business mailing address

6067 DECATUR BLVD
INDIANAPOLIS IN
46241-9606
US

V. Phone/Fax

Practice location:
  • Phone: 317-529-6679
  • Fax:
Mailing address:
  • Phone: 317-856-5201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number24357533
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: