Provider Demographics
NPI:1629336714
Name:CISCO, DONNA (LCSW, LCAC)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:CISCO
Suffix:
Gender:F
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:
Other - Last Name:SHINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:898 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1407
Mailing Address - Country:US
Mailing Address - Phone:317-887-1348
Mailing Address - Fax:317-883-5225
Practice Address - Street 1:898 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1407
Practice Address - Country:US
Practice Address - Phone:317-887-1348
Practice Address - Fax:317-883-5225
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005537A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical