Provider Demographics
NPI:1619746633
Name:SUPPLE, ABIGAIL
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:SUPPLE
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 1:3216 BALLARD LN
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-7200
Mailing Address - Country:US
Mailing Address - Phone:812-590-2157
Mailing Address - Fax:
Practice Address - Street 1:5155 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-3764
Practice Address - Country:US
Practice Address - Phone:812-590-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst