1710059779 NPI number — MS. STEPHANIE DIANE LOWE BURRY LCSW

Table of content: MS. STEPHANIE DIANE LOWE BURRY LCSW (NPI 1710059779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710059779 NPI number — MS. STEPHANIE DIANE LOWE BURRY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOWE BURRY
Provider First Name:
STEPHANIE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOWE SAGEBIEL
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710059779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5708 WINTHROP AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46220-2630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
173-439-7618
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8935 N MERIDIAN ST STE 225
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46260-5384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-439-7618
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  34005082A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201178980A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201163980 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: IN1231 . This is a "MEDICARE GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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