Provider Demographics
NPI:1588272322
Name:DEJANETTE, TEVA MICHELLE
Entity type:Individual
Prefix:
First Name:TEVA
Middle Name:MICHELLE
Last Name:DEJANETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TEVA
Other - Middle Name:MICHELLE
Other - Last Name:WEIGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:3771 S A ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-6053
Practice Address - Country:US
Practice Address - Phone:765-598-4192
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-127646106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician