Provider Demographics
NPI:1801412895
Name:CARRICO, LISA DIANE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:CARRICO
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 1:6640 INTECH BLVD STE 195
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-2014
Mailing Address - Country:US
Mailing Address - Phone:317-295-0608
Mailing Address - Fax:317-295-0622
Practice Address - Street 1:6640 INTECH BLVD STE 195
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2014
Practice Address - Country:US
Practice Address - Phone:317-295-0608
Practice Address - Fax:317-295-0622
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002668A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical