Provider Demographics
NPI:1588225551
Name:FOX, MISTY SHEA
Entity Type:Individual
Prefix:MS
First Name:MISTY
Middle Name:SHEA
Last Name:FOX
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 1:12650 HAMILTON CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5400
Mailing Address - Country:US
Mailing Address - Phone:317-249-2242
Mailing Address - Fax:317-663-1175
Practice Address - Street 1:3101 N CANTERBURY CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-1500
Practice Address - Country:US
Practice Address - Phone:317-249-2242
Practice Address - Fax:317-663-1175
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-19-34478103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst