MEDICARE: MADELON JOAN DRIBBLE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34005312A	IN

General Provider Information

NPI Number	:	1518182781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADELON JOAN DRIBBLE LCSW

Provider Business Mailing Address
First Line	:	7917 WINSTON LN
Second Line	:	4630 WEST JEFFERSON BLVD.
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5780
Country	:	US
Telephone Number	:	260-399-4357
Fax Number	:

Provider Business Practice Location Address
First Line	:	7917 WINSTON LN
Second Line	:	4630 WEST JEFFERSON BLVD.
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-5780
Country	:	US
Telephone Number	:	260-442-8892
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2007
Last Update Date	:	07/08/2007

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