Healthcare Provider Details

I. General information

NPI: 1700415213
Provider Name (Legal Business Name): KRISTY MARIE SHENE CAPRC II-MH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 N MERIDIAN ST STE 110
INDIANAPOLIS IN
46208-4674
US

IV. Provider business mailing address

3351 N MERIDIAN ST STE 110
INDIANAPOLIS IN
46208-4674
US

V. Phone/Fax

Practice location:
  • Phone: 317-964-0450
  • Fax: 317-964-0452
Mailing address:
  • Phone: 317-964-0450
  • Fax: 317-964-0452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: