1679743033 NPI number — MRS. SANDRA ELLEN CHAUHAN LCSW

Table of content: MRS. SANDRA ELLEN CHAUHAN LCSW (NPI 1679743033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679743033 NPI number — MRS. SANDRA ELLEN CHAUHAN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAUHAN
Provider First Name:
SANDRA
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
MRS.
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:
DREIBAND
Provider Other First Name:
SANDRA
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679743033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2121 LAKE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805-5100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-426-5431
Provider Business Mailing Address Fax Number:
260-421-1091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8708 WOODSTREAM DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-6564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-0974
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2008

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: 104100000X , with the licence number:  34004935A , 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)





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