Provider Demographics
NPI:1245629096
Name:ISHANPARA, POONAM (PSYD)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:ISHANPARA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6845 E US HIGHWAY 36 STE 500
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9781
Mailing Address - Country:US
Mailing Address - Phone:317-742-1340
Mailing Address - Fax:
Practice Address - Street 1:6845 E US HIGHWAY 36 STE 500
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-9781
Practice Address - Country:US
Practice Address - Phone:813-289-6597
Practice Address - Fax:813-289-6592
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
FLPY9504103T00000X
IN20042843A103TA0700X, 103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical