Basic Information
| Provider Information | |||||||||
| NPI: | 1871975771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROUSE | ||||||||
| FirstName: | MAURA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1026 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177776435 | ||||||||
| FaxNumber: | 3177776644 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 RILEY HOSPITAL DR | ||||||||
| Address2: | RI 5837 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179448167 | ||||||||
| FaxNumber: | 3179449760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2015 | ||||||||
| LastUpdateDate: | 12/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 20042921 | IN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 300000104 | 05 | IN | MEDICAID |