Healthcare Provider Details

I. General information

NPI: 1104273242
Provider Name (Legal Business Name): LA-KESHA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5650 CONGRESSIONAL PL
INDIANAPOLIS IN
46235-9710
US

IV. Provider business mailing address

5650 CONGRESSIONAL PL
INDIANAPOLIS IN
46235-9710
US

V. Phone/Fax

Practice location:
  • Phone: 317-756-8907
  • Fax:
Mailing address:
  • Phone: 317-756-8907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: