Healthcare Provider Details

I. General information

NPI: 1730213232
Provider Name (Legal Business Name): ELIZABETH ANNE YORK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S WALNUT ST STE 21
BLOOMINGTON IN
47404-6137
US

IV. Provider business mailing address

205 S WALNUT ST STE 21
BLOOMINGTON IN
47404-6137
US

V. Phone/Fax

Practice location:
  • Phone: 812-322-2788
  • Fax: 866-758-9013
Mailing address:
  • Phone: 812-322-2788
  • Fax: 866-758-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39000882A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number34002826A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: