Basic Information
| Provider Information | |||||||||
| NPI: | 1538228275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRANEY | ||||||||
| FirstName: | MARIETTA | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6626 E 75TH STREET | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176217561 | ||||||||
| FaxNumber: | 3173556096 | ||||||||
| Practice Location | |||||||||
| Address1: | 10872 PINE BLUFF DR | ||||||||
| Address2: | |||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460378929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175858019 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2006 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0808X | 71003770A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 104100000X | 33001799 | IN | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 71003770A | IN | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 163W00000X | 28074744 | IN | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 100270530A | 05 | IN | MEDICAID | P01191793 | 01 | IN | RR MEDICARE PTAN | OTHER |