=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366160822
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASIA NICOLE DEBERRY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2022
-----------------------------------------------------
Last Update Date | 11/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9156 GRANVILLE CT
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46229-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-993-4064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9156 GRANVILLE CT
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46229-2042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-993-4064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Psychologist
-----------------------------------------------------
License Number | 014956
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------