Provider Demographics
NPI:1649882093
Name:BIRCH, ELISE VICTORIA (MA-AT, LMHCA, ATR-P)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:VICTORIA
Last Name:BIRCH
Suffix:
Gender:F
Credentials:MA-AT, LMHCA, ATR-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6411 S EAST ST STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-2737
Mailing Address - Country:US
Mailing Address - Phone:317-780-5750
Mailing Address - Fax:317-780-5755
Practice Address - Street 1:6411 S EAST ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-2737
Practice Address - Country:US
Practice Address - Phone:317-780-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20-022221700000X
IN88001096A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist