Provider Demographics
NPI:1104365865
Name:CROSS, KETA
Entity Type:Individual
Prefix:
First Name:KETA
Middle Name:
Last Name:CROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4716 ROUND LAKE RD APT H
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-2386
Mailing Address - Country:US
Mailing Address - Phone:317-496-4730
Mailing Address - Fax:
Practice Address - Street 1:4716 ROUND LAKE RD APT H
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-2386
Practice Address - Country:US
Practice Address - Phone:317-496-4730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-14
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator