Healthcare Provider Details

I. General information

NPI: 1730826207
Provider Name (Legal Business Name): LIYA GEBRU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 E WASHINGTON ST STE E
INDIANAPOLIS IN
46229-2638
US

IV. Provider business mailing address

6562 WESTLAND DR
BROWNSBURG IN
46112-7412
US

V. Phone/Fax

Practice location:
  • Phone: 317-897-0200
  • Fax:
Mailing address:
  • Phone: 317-460-6378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12013802A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: