Provider Demographics
NPI:1295310894
Name:PADDACK, DESIREE (LMFT, LAC)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:PADDACK
Suffix:
Gender:F
Credentials:LMFT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8949 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-6829
Mailing Address - Country:US
Mailing Address - Phone:317-847-0747
Mailing Address - Fax:
Practice Address - Street 1:4755 KINGSWAY DR STE 318
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46205-1571
Practice Address - Country:US
Practice Address - Phone:317-402-9915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35002155A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist