1144322777 NPI number — MS. TAMARA L VANBAALEN LCSW

Table of content: MS. TAMARA L VANBAALEN LCSW (NPI 1144322777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144322777 NPI number — MS. TAMARA L VANBAALEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANBAALEN
Provider First Name:
TAMARA
Provider Middle Name:
L
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144322777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11109 PARKVIEW PLAZA DR # 117
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:
46845-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5693 YMCA PARK DR W
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:
46835-3280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-425-6500
Provider Business Practice Location Address Fax Number:
260-425-6505
Provider Enumeration Date:
09/03/2006

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:  34003564A , 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: 742863000 . This is a "MAGELLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200467310A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000341875 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 030305 . This is a "MHN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 7733638 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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