MEDICARE: THERESA JANE RADER-WILSON PSYD HSPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	20041299A	IN
2	103TC0700X	Clinical Psychologist	20041299A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255401220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA JANE RADER-WILSON PSYD HSPP

Provider Business Mailing Address
First Line	:	6626 E 75TH STREET
Second Line	:	STE 500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:	317-621-7561
Fax Number	:	317-355-6096

Provider Business Practice Location Address
First Line	:	8711 US 31 S
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46227-6252
Country	:	US
Telephone Number	:	317-887-7771
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	11/27/2023

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