Provider Demographics
NPI:1366160822
Name:DEBERRY, ASIA NICOLE
Entity type:Individual
Prefix:
First Name:ASIA
Middle Name:NICOLE
Last Name:DEBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9156 GRANVILLE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-2042
Mailing Address - Country:US
Mailing Address - Phone:317-993-4064
Mailing Address - Fax:
Practice Address - Street 1:9156 GRANVILLE CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2042
Practice Address - Country:US
Practice Address - Phone:317-993-4064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN014956103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININDIANAPOLISOtherI DON’T HAVE MEDICAID BILLING NUMBER YET