1699829648 NPI number — MRS. HOLLY R LICHTSINN LCSW

Table of content: MRS. HOLLY R LICHTSINN LCSW (NPI 1699829648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699829648 NPI number — MRS. HOLLY R LICHTSINN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LICHTSINN
Provider First Name:
HOLLY
Provider Middle Name:
R
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:
FRIER
Provider Other First Name:
HOLLY
Provider Other Middle Name:
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:
1699829648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10319 DAWSONS CREEK BLVD
Provider Second Line Business Mailing Address:
SUITE H
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-969-5583
Provider Business Mailing Address Fax Number:
260-969-5584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10319 DAWSONS CREEK BLVD
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-1911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-969-5583
Provider Business Practice Location Address Fax Number:
260-969-5584
Provider Enumeration Date:
01/23/2007

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100124250 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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