Provider Demographics
NPI:1356583223
Name:THEOHARIS, KARRIE ANN HINES (CGC)
Entity type:Individual
Prefix:
First Name:KARRIE
Middle Name:ANN HINES
Last Name:THEOHARIS
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:KARRIE
Other - Middle Name:A
Other - Last Name:HINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44730
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46244-0730
Mailing Address - Country:US
Mailing Address - Phone:317-274-7879
Mailing Address - Fax:317-278-9918
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:UH 2440
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-274-8231
Practice Address - Fax:317-278-9918
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X
IN74000012A170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1356583223OtherANTHEM PTAN
IN000001474517OtherANTHEM PTAN
IN300028065Medicaid
IN000001227229OtherANTHEM PTAN