MEDICARE: PHILLIP I. SUBECK 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	992328	CO
2	1041C0700X	Clinical Social Worker	34005906A	IN

General Provider Information

NPI Number	:	1750521837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP I. SUBECK LCSW

Provider Business Mailing Address
First Line	:	115 FARABEE DR N
Second Line	:	SUITE B-2
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5913
Country	:	US
Telephone Number	:	765-404-9023
Fax Number	:	765-423-5600

Provider Business Practice Location Address
First Line	:	115 FARABEE DR N
Second Line	:	SUITE B-2
City	:	LAFAYETTE
State	:	IN
Zip	:	47905-5913
Country	:	US
Telephone Number	:	765-404-9023
Fax Number	:	765-423-5600

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

Provider Enumeration Date	:	03/02/2009
Last Update Date	:	09/13/2011

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