MEDICARE: HEATHER C SMALLEY CADAC II

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	C2-51331	IN

General Provider Information

NPI Number	:	1912693599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER C SMALLEY CADAC II

Provider Business Mailing Address
First Line	:	9821 CRYSTAL COVE CT
Second Line	:
City	:	NEW HAVEN
State	:	IN
Zip	:	46774-2803
Country	:	US
Telephone Number	:	260-310-9086
Fax Number	:

Provider Business Practice Location Address
First Line	:	3282 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2883
Country	:	US
Telephone Number	:	812-200-2789
Fax Number	:

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

Provider Enumeration Date	:	04/17/2023
Last Update Date	:	04/17/2023

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