Basic Information
| Provider Information | |||||||||
| NPI: | 1205173994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CIESLINSKI | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PFMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284886 | ||||||||
| FaxNumber: | 3178598239 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 JOLIET ST | ||||||||
| Address2: | |||||||||
| City: | DYER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463111705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193225747 | ||||||||
| FaxNumber: | 2198642282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2013 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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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 | 163W00000X | 28205748A | IN | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 71004267A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MC2797821 | 01 | IN | DEA | OTHER |