Provider Demographics
NPI:1972999068
Name:CROSS, INDIA A (BS)
Entity Type:Individual
Prefix:MS
First Name:INDIA
Middle Name:A
Last Name:CROSS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 CAPERNIUM RD TRLR 2
Mailing Address - Street 2:TR#2
Mailing Address - City:CHERRYVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28021-9404
Mailing Address - Country:US
Mailing Address - Phone:704-769-4075
Mailing Address - Fax:704-769-4136
Practice Address - Street 1:2134 CAPERNIUM RD TRLR 2
Practice Address - Street 2:TR#2
Practice Address - City:CHERRYVILLE
Practice Address - State:NC
Practice Address - Zip Code:28021-9404
Practice Address - Country:US
Practice Address - Phone:704-769-4075
Practice Address - Fax:704-769-4136
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC251S00000XMedicaid
NC251Medicaid