1760565055 NPI number — CAROL JOANN BEATHEA PHD LCSW MSW

Table of content: CAROL JOANN BEATHEA PHD LCSW MSW (NPI 1760565055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760565055 NPI number — CAROL JOANN BEATHEA PHD LCSW MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEATHEA
Provider First Name:
CAROL
Provider Middle Name:
JOANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD LCSW MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEATHEA
Provider Other First Name:
C
Provider Other Middle Name:
JOANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD MSW LCSW
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1760565055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 W LEXINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-293-5991
Provider Business Mailing Address Fax Number:
574-293-5429

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 W LEXINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-293-5991
Provider Business Practice Location Address Fax Number:
574-293-5429
Provider Enumeration Date:
10/23/2006

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: 104100000X , with the licence number:  34000509A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 106H00000X , with the licence number: 34000509A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 000000183551 . This is a "BCBS ANTHEM" identifier . This identifiers is of the category "OTHER".




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