Basic Information
| Provider Information | |||||||||
| NPI: | 1124473749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6640 INTECH BLVD STE 195 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462782014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172950608 | ||||||||
| FaxNumber: | 3179480609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2016 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01087770A | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | 310168 | LA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0804X | 01087770A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.