=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205173994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA M CIESLINSKI PFMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2013
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 JOLIET ST
-----------------------------------------------------
City | DYER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46311-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-322-5747
-----------------------------------------------------
Fax | 219-864-2282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1040 SIERRA DR SUITE 400
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46143-7240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-528-4886
-----------------------------------------------------
Fax | 317-859-8239
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 28205748A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 71004267A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------