Healthcare Provider Details

I. General information

NPI: 1679357420
Provider Name (Legal Business Name): IAN HULETTE LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S ELM ST APT 3
CHAMPAIGN IL
61820-5085
US

IV. Provider business mailing address

47 GREAT HORNED DR
OXFORD OH
45056-3522
US

V. Phone/Fax

Practice location:
  • Phone: 217-670-3837
  • Fax:
Mailing address:
  • Phone: 217-670-3837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2608645
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.041470
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: