Provider Demographics
NPI:1255401220
Name:RADER-WILSON, THERESA JANE (PSYD HSPP)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:JANE
Last Name:RADER-WILSON
Suffix:
Gender:F
Credentials:PSYD HSPP
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:JANE
Other - Last Name:RADER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD HSPP
Mailing Address - Street 1:6626 E 75TH STREET
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7561
Mailing Address - Fax:317-355-6096
Practice Address - Street 1:8711 US 31 S
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6252
Practice Address - Country:US
Practice Address - Phone:317-887-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041299A103TA0400X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200389320Medicaid
IN266180021Medicare PIN
INM400015677Medicare UPIN
IN266180021Medicare PIN
INM400073205Medicare PIN