Provider Demographics
NPI:1124516257
Name:ITZA, SHEREE (MED, LCAC)
Entity type:Individual
Prefix:
First Name:SHEREE
Middle Name:
Last Name:ITZA
Suffix:
Gender:F
Credentials:MED, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 E US HIGHWAY 36 STE 100
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-6646
Mailing Address - Country:US
Mailing Address - Phone:888-714-1927
Mailing Address - Fax:317-745-9565
Practice Address - Street 1:6655 E US HIGHWAY 36 STE 100
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123
Practice Address - Country:US
Practice Address - Phone:888-714-1927
Practice Address - Fax:317-745-9565
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000203A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)