Basic Information
| Provider Information | |||||||||
| NPI: | 1255401220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADER-WILSON | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD HSPP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RADER | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | JANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD HSPP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6626 E 75TH STREET | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3173556096 | ||||||||
| Practice Location | |||||||||
| Address1: | 8711 US 31 S | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462276252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178877771 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0400X | 20041299A | IN | N | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) | 103TC0700X | 20041299A | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 200389320 | 05 | IN | MEDICAID |