Provider Demographics
NPI:1568033975
Name:LITTLE, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:LITTLE
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 1:216 W 10TH ST # 563
Mailing Address - Street 2:
Mailing Address - City:LAPEL
Mailing Address - State:IN
Mailing Address - Zip Code:46051-9774
Mailing Address - Country:US
Mailing Address - Phone:765-635-4860
Mailing Address - Fax:
Practice Address - Street 1:8350 CRAIG ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-3593
Practice Address - Country:US
Practice Address - Phone:317-578-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician